ORIGINAL ARTICLE

Measuring Satisfaction with Nursing Care of Patients Admitted in the

Medical Wards of the Philippine General Hospital
Maria Vanessa C. Villarruz-Sulit1,2, Antonio L. Dans1,3 and Mark Anthony U. Javelosa1,4

Section of Adult Medicine, Adult Medicine Research Unit, Department of Medicine, Philippine General Hospital, University of the Philippines Manila
1

2
College of Nursing, University of the Philippines Manila
3
Department of Clinical Epidemiology, College of Medicine, University of the Philippines Manila
4
School of Statistics, University of the Philippines Diliman, Quezon City

Abstract important to patients.3 Likewise, the Joint Commission of

Objective. The main aim of this study was to determine patient Accreditation of Health Care Organizations (JACHO, 1994)
satisfaction with nursing care (PSNC) in the medical wards of the has also considered patient satisfaction as a valid indicator
UP-Philippine General Hospital (UP-PGH) using a valid and reliable for accreditation.4
locally developed UP-PGH PSNC questionnaire. Patients are often generally satisfied with the healthcare
they receive although they may not be uniformly satisfied
Methods. The survey utilized a cross-sectional study design and with all aspects of care.5 Of all these aspects, a major service
was conducted in the medical wards of the UP-PGH in 2006. A that hospitalized patients are exposed to is nursing care,
total of 237 patients were included in the survey. with nursing personnel comprising the largest proportion of
the health service community.6 It is also important to note
Results. Over a third or 34.3% (95% CI 28%, 40%) and 35% (95% CI that since most of the healthcare in hospitals is nursing care,
26%, 44%) were highly satisfied with their experience regarding nursing care most closely influences the patients’ satisfaction
the nurses’ caring attitude and the nurses’ skill/competence with the overall quality of care.6,7 Therefore, the importance
respectively. Fewer respondents were highly satisfied with the of measuring patient satisfaction with nursing care cannot be
nurses as information providers, with only 17.2% (95% CI 12%, emphasized enough.
22%) saying they were highly satisfied. A little over half or 57.8% Patient satisfaction with nursing care was conceptualized
(95% CI 52%, 64%) were highly satisfied in the overall evaluation by Risser (1975) as the degree of congruence between a
of care. patient’s expectations of ideal nursing care and his perception
of the real nursing care he receives.1 Most definitions would
Conclusion. The patients were satisfied with the nursing care definitely have certain elements of subjectivity including
provided in two dimensions: The nurse as a caring person one definition which states that it is a measure of a patient’s
and the nurse as a skilled and competent healthcare provider, or a family’s opinion of the care received from the nursing
although only about a third indicated that they were highly staff.6,8 In light of these definitions, it is therefore necessary
satisfied. Nevertheless, 57.8% were highly satisfied in the overall to include patients’ input on what is important to them when
evaluation of care, but these patients may have considered other developing the measurement tool. In fact, patients’ opinions
hospital services and cost. Other factors that might affect patient in assessments of health services have been used greatly
satisfaction need to be explored and the use of other evaluation over the past 25 years.9,10 It is thus crucial that, in any patient
tools to augment these findings is recommended. satisfaction survey, the instrument should capture patients’
expectations and perceptions, thereby providing accurate
Keywords: patient satisfaction, nursing care, quality of care measures of their level of satisfaction with the service.

Introduction The UP-PGH PSNC Questionnaire

Measuring quality of care in the hospital setting has The UP-PGH PSNC questionnaire was developed as
become very important in evaluating healthcare services. an attempt to create a valid and reliable tool that considers
The U.S. National Center for Health Services Research and patients’ views. It was made in two phases that included
Development (NCHSRD 1970), for instance, assessed the qualitative and quantitative methods. Dimensions were
degree of system efficiency and effectiveness in meeting established at the onset based on a review of literature.
the demands and needs of patients. Their criteria for the These were identified as follows: (1) the nurse as a caring
evaluation of the performance of the healthcare system person, (2) the nurse as an information provider and (3) the
were classified into three categories: mortality, morbidity, nurse as a competent and skilled healthcare provider. These
and patient satisfaction.1 Patient satisfaction is probably the dimensions follow the themes similar to Risser’s scale which
most difficult to measure among the three, but its importance had the following dimensions: (1) interpersonal-trusting, (2)
in determining quality of care cannot be set aside.2 In fact, interpersonal-educational, and (3) technical-professional.1,11
in Canadian hospitals, even though there are generally no The qualitative phase involved conducting key informant
standards for acceptable levels of satisfaction, knowledge interviews with nine patients admitted in the medical wards
gained from patient satisfaction surveys can set a direction including their watchers to determine what expectations
for quality improvement as the focus is on outcomes that are and perceptions they had for nursing care that affect
their satisfaction. As watchers are primary figures in the
hospitalized life of Filipinos, their views were also explored
Corresponding author: Maria Vanessa C. Villarruz-Sulit, RN, MSc to determine whether these were consistent with the patient’s
Section of Adult Medicine and Medical Research Unit, views. The key informants were carefully selected to reflect the
Department of Medicine, characteristics of the group under study, that is, hospitalized
Philippine General Hospital
Taft Avenue, Manila, 1000 Philippines patients. Therefore, patients in the medical wards with

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 Measuring Satisfaction with Nursing Care of Patients

different backgrounds, ages, and affiliations were chosen. A

panel of 10 nurses from the hospital’s Department of Nursing Methods
Education and Training (DNET), well-versed in defining the Study design & setting
roles and responsibilities of the UP-PGH nurse, were also This study utilized a cross-sectional, analytic study design
approached to confirm whether what the patients considered to determine the level of satisfaction with nursing care of
nursing care activities were really part of a UP-PGH nurses’ patients admitted to the medical wards using the locally
job description. This was done to ensure that the care that is developed UP-PGH PSNC questionnaire. The study took
important to the patients is the care that is actually given by the place in the adult medicine charity (wards 1 and 3) and pay
nurses in the wards. Patients and watchers views regarding wards (from 4th to 7th floor) of UP-PGH, Manila.
nursing care were found to be consistent with each other Since interviews obtain substantially higher response rates
and the panel of 10 nursing experts from DNET confirmed that may lessen worry about non-response bias,13 the UP-
that these were indeed nursing care activities expected in the PGH PSNC questionnaire was administered with interviewer
care of patients admitted at the medical wards of UP-PGH. assistance.
Although this phase of questionnaire development was a
lengthy process it was needed to ensure content validity. Study subjects & sample size
The questionnaire was pre-tested using a quantitative Patients were included in the survey if they satisfied the
method. The initial 60-item tool was fielded among 186 following inclusion criteria: (1) adults, aged 18 years and
patients in the medical wards to determine the questionnaire’s above; (2) conscious, coherent, and oriented to time, person
interpretability in terms of: comprehensibility, ambiguity, and place; (3) admitted in the medical wards for at least three
presence of double-barreled questions and length of items. days and ready for discharge; and (4) willing to give informed
The 186 patients were recruited consecutively as they were consent.
about to be discharged, using the method that was planned The sample size was based on the rule of 200 (Gorsuch
for the actual survey. Item analysis was conducted to 1983) where a minimum goal of 200 responses must be
establish the reliability of the instrument and to determine achieved.14 Utilizing a convenience sampling approach,
which items needed to be discarded. Patients’ suggestions patients for discharge were invited to the survey. As much
were also considered in determining what items to retain or as possible data collection was done to cover Mondays to
remove. A final instrument was then generated containing 15 Sundays. A list of patients for possible discharge was obtained
items and four questions on the overall evaluation of care as once at 10AM and another at around 2PM. Only those on the
enumerated in Table 1. list were approached consecutively. Patients discharged in the
Cronbach’s alphas were computed for this final instrument. evenings were not included.
The alpha for the dimension “nurse as a caring person” was
0.54, while the dimensions “nurse as a competent and skilled Description of the procedure/outcome measures
healthcare worker” and “nurse as an information provider” The UP-PGH PSNC questionnaire was primarily
had alphas of 0.74 and 0.62, respectively. Cronbach’s alpha developed as a tool to use in the adult medical wards of
was also computed for the items on overall evaluation of care the UP-PGH. Prior to the administration of the tool for the
showing an alpha of 0.79. These values indicate that the items purpose of this research, technical and ethics approval was
have an acceptable to a high degree of internal consistency. sought and permission to conduct the study in all the medical
The final UP-PGH PSNC questionnaire was further refined wards was also requested.
and had two versions, an English and a Tagalog version. The A neutral person other than the researcher or a member
English version was translated to Tagalog and back translated of the nursing team was trained to obtain consent and
into English independently to ensure that items in both administer the UP-PGH PSNC questionnaire privately and
versions would be understood in the same manner. This final maintain confidentiality throughout the process. Before the
tool contained 19 items, four of which were for assessing the interviewer left the area, all the questionnaires were checked
overall evaluation of care. Responses were made on a five- for completeness.
point Likert scale that patients score from 1–totally disagree— After data collection, responses were encoded and
to 5–totally agree—indicating a totally unsatisfying to a highly quantitative analysis was done using descriptive statistics.
satisfying experience. A section on demographic details was Percentages were computed per response category and the
also included. level of satisfaction was computed per dimension as well as
the overall evaluation of care.
On using the UP-PGH PSNC Questionnaire
Dozens of patient satisfaction instruments have been Results
developed through the years; however, the literature offers There were 237 patients included and analyzed in this
comparatively few reports of patient satisfaction research survey. Mean age was calculated at 50 years old (SD 17),
in developing countries.12 Issues related to feasibility and ranging from 18 to 93 years old. There was an almost equal
methodology may have caused the dearth in local patient distribution between males and females, two thirds of whom
satisfaction studies. Realizing that what patients say plays were married. A little over half had previous hospitalization
a crucial role in eventually improving their healthcare, but no specifics were obtained. Table 2 shows the socio-
the healthcare delivery system and possibly healthcare demographic characteristics in detail.
compliance, the Philippines can benefit greatly from such Patients were generally very accommodating of the
endeavors. As an initial step, the locally developed UP-PGH interviewer and were more comfortable discussing their
PSNC questionnaire was used to measure patient satisfaction responses to the questionnaire with a neutral person. Because
in adult medicine wards not only to determine the level of the interviewer-assisted process, completeness of data
of satisfaction of these patients, but also to a assess the was assured and non-response to items was basically due
experience of conducting a survey, find areas of improvement, to patients not being exposed to that particular kind of care,
and provide baseline information in the improvement of e.g., wound care or injection administration. Even though a
evaluation methods. comments section was provided, none of the patients wrote

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Measuring Satisfaction with Nursing Care of Patients

Table 1. Items in the UP-PGH PSNC Questionnaire per dimension Table 2. Characteristics of surveyed patients

Characteristics Mean (SD) Median

Dimension 1. The Nurse as a Caring Person or Percent 52
a. Nurses are always cheerful Age 49.99 (16.94) 8
b. Nurses give me less attention Hospital Days 11.14 (9.46) 24
c. Nurses are cranky Hours with Watcher 20.96 (5.46)
d. Nurses are always in a hurry Age Group
e. Nurses do not introduce themselves 18-30 years old 18.14%
Dimension 2. The Nurse as an Information Provider >30-50 years old 30.38%
a. Nurses tell me the side effects of my medications >50 years old and above 51.48%
b. Nurses tell my watchers the side effects of my medications Sex
c. Nurses advice me on proper diet Male 48.52%
d. Nurses advice me on what activities I can do at home after discharge Female 51.48%
e. Nurses tell me immediately what my test results are Medical Condition
f. Nurses do not explain hospital policies, rules & regulations Acute Illness/Conditions 42.19%
Dimension 3. The Nurse as a Competent and Skilled Healthcare Provider Chronic Illness/Conditions 57.81%
a. I feel only a little pain when nurses give injections Ward Service Type
b. I feel only a little pain when nurses prick my finger to obtain blood for Charity 45.30%
tests Pay 55.70%
c. Nurses dress my wounds carefully Educational Attainment
d. Nurses assist doctors in procedures Elementary Graduate 24.47%
Overall Evaluation of Care High School Graduate 33.76%
a. If I get sick again & need hospitalization, I want to come back to UP- College Graduate 35.44%
PGH or this ward Vocational 3.80%
b. Overall, the nursing care I received met my expectations None 0.84%
c. Overall, I am satisfied with the nursing care I received Civil Status
d. I will recommend UP-PGH to my family and friends. Single 19.41%
Married 71.73%
any comments. Widowed/Separated 8.86%
The distribution of patient responses across the scale of Occupation
1–totally disagree, 2—disagree, 3—uncertain, 4—agree, 5– Blue Collar (general/skilled laborers, & 21.94%
totally agree, was computed for every dimension. The results military)
are summarized in Table 3. White Collar (professionals & businessmen) 16.03%
Patient responses are clustered more towards “agree” and Vendors 4.22%
“totally agree” in dimensions 1, 3, and the overall evaluation Unemployed 56.12%
of care. This indicates that most of the patients were Others (artists, events coordinators) 1.69%
generally happy with their nursing experiences in these two Income Group (in PhP)
dimensions and in their overall evaluation. However, more No income 54.43%
patients responded with “agree” than “totally agree” in the 1-5,000 9.28%
two dimensions, indicating just a satisfying experience. On 5,001-10,000 24.47%
the other hand, in the overall evaluation of care, the majority 10,001-15,000 6.33%
answered “totally agree”, indicating a highly satisfying >15,001 5.48%
experience. Relationship of Watcher to Patient
Dimension 2 showed a different distribution altogether Parent 10.13%
with only 17.2% highly satisfied respondents. Most of the Spouse 35.02%
patients responded with either “disagree” or “agree”. Patients Child 25.32%
seemed equally divided between a positive and a negative Other Relatives 22.78%
response to their experience with nurses as information Unrelated 6.74%
providers. Although the trend showed more patients Hours with Watcher
indicating a satisfying experience, the difference between 1-8 Hours 6.45%
the percentage of satisfied and dissatisfied patients in this >8-16 Hours 18.82%
dimension was small. >16-24 Hours 74.73%
Previous Hospitalization
Discussion PGH 21.94%
There were several issues raised by this paper and these Other Government Hospitals 0.84%
are as follows: Private Hospitals 23.21%
1. The use of the UP-PGH PSNC questionnaire as a survey None 54.01%
tool for the hospital’s medical wards;
2. The tool’s sensitivity in obtaining satisfaction levels;
3. The concept of satisfaction among patients confined in
hospital-stay settings and therefore more appropriate for
UP-PGH.
use. The questionnaire was actually easy to administer and
The UP-PGH PSNC Questionnaire as a survey tool
patients were able to fill up the forms quickly; however,
This final questionnaire was generated from an original
it may be a different matter altogether if this was used as
60-item version which the patients had a very difficult
a self-administered instrument. The fact that the response
time completing primarily because of its length. The 19-
and completeness rate was high was due to the presence of
item version proved to be less intimidating even in short

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 Measuring Satisfaction with Nursing Care of Patients

a neutral person administering the instrument. This hiring sought jobs in higher paying countries and are replaced by
of a neutral person might not be feasible in this government neophytes. Nurses are required by the hospital to stay for at
institution at this time. The possibility of using ward staff, least two years, but not all nurses finish their contracts. This
on the other hand, is strongly discouraged, but there may be situation is not only present in UP-PGH but in other hospitals
advantages as well. The disadvantage is that patients may as well. Perhaps this can partly explain why more Filipino
feel pressured to answer positively and eventually might not patients were just satisfied and not highly satisfied with their
complete and forward the form to the ward staff. An advantage nurses in this area of care.
is that nurses will feel involved in the process and will always Several studies have shown the importance of providing
be aware that they need to perform their best. Whether it communication and adequate information to patients and
is more feasible to have non-nursing staff involved in the also citing the most common cause of dissatisfaction as the
nurses’ inability to provide sufficient information.15 In the
Table 3. Percent distribution of patient responses by dimension or development of the instrument, patients often verbalized
category their need to know hospital policies, vital signs, test results,
diet and discharge plans. Though they did not expect much
Dimension / 1 2 3 4 5
information from their nurses regarding their medical
Category Totally Disagree Uncertain Agree Totally
condition and even their management plan, they felt additional
disagree % % % % agree %
information from the nurse about these were still important
(95% CI) (95% CI) (95% CI) (95% CI) (95% CI)
and helpful. Obviously, nurses have failed in providing them
Dimension 1: 0% 3.0% 14.8% 47.9% 34.3%
with much needed information as only a few were highly
The nurse as a (0.8%, 5%) (10%, 19%) (41%, 54%) (28%, 40%)
satisfied. A third of the patients responded towards the
caring person
negative side of the scale. This is probably the most neglected
Dimension 2: 6.2% 30.8% 0% 45.8% 17.2%
duty of nurses in UP-PGH. It is not, however, an impossible
The nurse as (3%, 9%) (25%, 37%) (39%, 52%) (12%, 22%)
or time consuming task. Once a nurse has established rapport
an information
with the patient, the nurse can always bring a little piece of
provider
information at every bedside visit. Whether these bedside
Dimension 3: 0.8% 2.5% 15.8% 45.8% 35%
visits are frequent or few, depending on how sick or well a
The nurse as a (0.8%, 2.5%) (0.03%, 5%) (9%, 22%) (37%, 55%) (26%, 44%)
patient has become, imparting information may well improve
skilled & com-
a nurse-patient relationship.
petent health
Even though patient responses to their nursing experience
care provider
were more on the “agree” portion of the scale signifying average
Overall evalua- 0.4% 1.3% 5.1% 35.4% 57.8%
satisfaction levels, more than half of the patients responded as
tion of care (0.4%, 1.3%) (0.2%, 2.3%) (2.3%, 8%) (29%, 42%) (52%, 64%)
highly satisfied in terms of their overall evaluation of care.
Upon reviewing the items in this global evaluation, it was
distribution and collection of the questionnaires or whether noted that the focus shifted to more general questions like
there is a need for additional time and effort to accomplish willingness to come back to the hospital and recommending
this task, may be subject to several discussions on different the hospital to family and friends. Patients, when responding
levels of management that goes beyond just determining to these questions may have also considered other aspects of
patient satisfaction. hospital service, such as the doctors, the environment, and
other services including assistance from social workers. Cost
The sensitivity of the UP-PGH PSNC Questionnaire may have also played a part in the evaluation since it is still
The questionnaire was developed by gathering the cheaper to be hospitalized in UP-PGH than a service ward
perceptions, expectations and opinions of patients’ on their in a private hospital. Also, it seemed that the more broadly a
nursing care experience. It was hoped that the instrument question was phrased, the more likely a positive response was
being more attuned to Filipino patients’ views was able to given. In a way, the details of nursing care as reflected in the
truly capture how Filipino patients regard the nursing care rest of the items in the questionnaire provide a more explicit
they receive. Its uniqueness also lies in the fact that the tool review of the experience and thus patients can adequately
was developed with the involvement of the receivers of care judge each experience.
themselves–the patients. Looking at the results, one would immediately see that
A patient’s relationship with a nurse characterized by patients were generally happy with the nursing care they
understanding, respect, trust, honesty, cooperation personal received from UP-PGH nurses. Upon closer inspection of the
attention, patience and humor was most often related to a results of each dimension, however, more meaningful results
high level of satisfaction.16 This was also mentioned quite were seen, and this reflected well upon the usefulness and
often and emphasized by patients and their watchers in the sensitivity of the tool in discriminating between less satisfied
initial phase of this study. It would not be surprising therefore and more satisfied. Also, other factors need to be explored as
that the patients would rate their experience with nurses who well to explain the trends of the responses.
were less pleasant and did not provide much attention to them
as average. This result was actually reflected in the survey. The UP-PGH patients’ concept of satisfaction
Regarding competency and skill, a nurse that does work in Filipino patients who have health insurance or have a
a technically correct manner was an important factor to patient little saved up for medical emergencies will probably not
satisfaction16 with the absence of physical pain resulting in a seek help in a government hospital. The predicaments of
higher level of satisfaction.9 Patients expected nurses to be patients confined in the UP-PGH are obvious. One need only
able to assist doctors in procedures, give injections and prick walk by the medical wards to realize how dire circumstances
fingers without much pain. Of course these skills need to are among those confined. Filipino patients are known for
be mastered over time and with constant practice, but with their humor even in the face of adversity and thus may be
the high turnover rate of nurses in the wards, nurses keep pleased with just a little attention or an ounce of hope. It is not
changing regularly. Those who have mastered the skill have surprising that most patients would be most understanding

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Measuring Satisfaction with Nursing Care of Patients

when it comes to their nurses by just observing the load their Acknowledgment
nurses are faced with everyday. The author would like to sincerely thank and acknowledge the valuable
Determining how satisfied patients are who are perhaps contribution and guidance of the following people in the completion of this
research work: Dr. Leonila Dans, Prof. Nina Castillo-Carandang, Prof. Araceli
already at a low point in their lives may be inappropriate Balabagno, and Prof. Lourdes Amarillo. The authors are also grateful to the
after all. Patients know that they are entering an institution Research Implementation and Development Office of the UP-College of
catering to hundreds of people a day, training hundreds of Medicine for providing grant support for this study, and the Adult Medicine
students, with just the basic equipment, with overflowing Research Unit for subsidizing the author’s education. Much appreciation is also
extended to Cila, Gem, Joan, Owen, Bambi, Nat, the author’s family and the
wards and with staffing problems. They probably consider patients of UP-PGH. Special thanks are also given to Dr. Dennis Sulit and Jyo
these things as they respond to questionnaires on patient Sulit.
satisfaction and would probably have pre-formed opinions in
light of the situation. Patients may have the tendency to adjust
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