Assessment of Adult Patients Satisfaction with the Nursing Care in the Public Teaching Hospitals of Mosul City

Background: Patients have the right to expect quality of care. Patient satisfaction with nursing care is considered an important factor in explaining patients' perceptions of service quality, and a sound rationale for making the organization and delivery of health care responsive to consumer (client) opinion.
Objectives: The objectives of the study were to assess the adult patients satisfaction about the nursing care in the public teaching hospitals of Mosul city.
Methodology: A descriptive designed was carried-out in 1st of November 2012 through the 1st April 2013, and conduct in four hospitals in the Mosul city (Ibn-Sina, Al-Jamhory, Al-Salam, and Al-Kanssa teaching hospitals). A random sample was used for selecting (418) participation, and consisted of (160) male and (258) female. The questionnaire research which correct by the (8) experts, and used the Coefficient Correlation for questionnaire items showed that the reliability of the questionnaire which was (r = 0.88), the data were analyzed through the application of descriptive statistical analysis that include (frequency, and percentage), and application of inferential statistical analysis that include (Analysis of variance).
Results: The study had revealed that an age group (21-30 years) represent the greater percentage of the sample which constitutes (30.9%) of the patients, and the percentage of dissatisfaction was (60%, 53%, 58%, 51%) in Ibn-Sina, Al-Jamhory, Al-Salam, and Al-Kanssa teaching hospitals respectively, and found a significant association between patient satisfaction and (age, number of days stay in hospital, and previous admission to hospital).
Conclusions: The study concluded that most of the patients are dissatisfied with the nursing care in hospitals, and patient satisfaction was influenced by the age of the patient and days of stay in the hospital, also if patient has a previous admission to the hospital).
Recommendation: The present study recommended the development the communication skills between nurses and patient to providing high quality of nursing care and completely patient satisfaction. Working to improve nursing care services by using guidelines in hospitals to measuring patient satisfaction


INTRODUCTION
A hospital is an institution that provides a broad range of nursing services to sick, injured, or pregnant patients.It employs medical, nursing, and support staff to provide inpatient care to people who require close nursing monitoring and an outpatient care to people who need ambulatory care (1).Patient satisfaction is the patient's perception of care received compared with the care expected (2) .During hospitalization, patient satisfaction represents a balance between the patient's perception and expectation of their nursing care (3) .On the other hand, patient's satisfaction has been associated with improved patient compliance with therapy that presumably leads to better health outcomes.Nurses and other health-care professionals play a key role in providing support and information (4) .Eriksen defined patients' satisfaction as the patients' subjective evaluation of the cognitive-emotional response resulting from the interaction between the expectations of nursing care and the perception of actual nurse behaviors /characteristic.In addition, patients' opinions are important because they are the best source that can tell the providers of what is important, that is why this information can be used in health-care planning and evaluation (5) .Patients' satisfaction is viewed as a mediator between patients' perceptions of quality and their future intentions to reuse the service or recommend the hospital to family and friends (6) .The nursing staff occupies a prominent position to influence on the patient satisfaction with the service provided, as they are responsible to provide direct care to patients, to organize the care, and to coordinate their function with other hospital services.In addition, they comprise the major part of the health staff (7).Finally measuring patient satisfaction allows the identification of possible problems and suggests ways of improving the quality of care or public health interventions (8).Throughout the world patient satisfaction studies are widely used to evaluate the quality of care as well as public health programs' acceptability and impact (9).OBJECTIVES 1.To assess the association between adult patient satisfaction with some demographic data (age, sex, occupation, level of education, name of the hospital, and number of nurse in the ward).2. To identify the association between adult patient satisfaction with hospital information (name of the hospital, and number of nurse in the ward) and personal history (number of daysstayin the hospital, previous admission, and other diseases).

METHODOLOGY
A descriptive study was designed to determine the adult patient satisfaction with the nursing care in the hospitals of Mosul city.The study started in the 1 st of November 2012 to the 1 st April 2013, and conduct public teaching hospitals in the Mosul city, in the right side of the Tigris River found Ibn-Sina teaching hospital and Al-Jamhory teaching hospital, while in the left side of the Tigris River found Al-Salam teaching hospital and Al-Kanssa teaching hospital.A random sample was used for selecting (418) participation, and consisted of (160) male and (258) female.The data is collect from the adult patient participation in the four hospitals for period from 25 th December 2012 to the 10 th February 2013, by using a questionnaire constructed depending of the previous study and related to the literature (10) .
The questionnaire divided to part one is related to the demographical data about the sample (age, sex, occupation, and educational level), part two it is including hospital information this part consisted two questions about (name of the hospital, and number of the nurses in the ward), part three is related to the personal history of the sample and include (number of days overnight in hospital, do you have previous admission to the hospital, and do you have other diseases, in addition to the current disease), and part four of the questionnaire consist of the ( 12) question about the patient opinion about the nursing care.These items were measured by three scale options were used in the rating scale: (1) not satisfied, (2) quite satisfied, and (3) completely satisfied, the mean of score depended as a patients satisfaction was (≥1.65),To ensure the validity of the questionnaire from instrument of the study was established through penal of (8) experts chosen from University of Mosul / College of Nursing to examine the questionnaire, and used the Coefficient Correlation for items which showed that the reliability estimate for questionnaire was (r = 0.88).The data were analyzed through the application of descriptive statistical analysis that include (frequency, and percentage), and application of inferential statistical analysis that include (Analysis of variance) This table revealed that the highest percentage were (25.6%) for Ibn-Sina teaching hospital, and (68.7%) for number of nurses between (4-6 nurses) who give nursing care in the ward, and consisted majority percentage (82.3%)for the number of day stay in hospital between (1-5 days), and highest percentage (60.3%)were previous admission.While the higher percentage (68.2%)was patient not have other diseases in addition to the current disease.This table indicates a significant difference between mean score patient satisfaction with nursing care and their number of days staying in hospital, and patient previous admission to the hospital, but shows no significant difference between mean patient satisfaction with nursing care and their name of the hospital, number of the nurses in the ward, and if patient have other diseases in addition to the current disease by using analysis of variance.

Figure (1) distribution percentage of the patient completely satisfaction and not satisfied with the nursing care in the hospitals
This figure shows the level of patient satisfaction (40 %) of patients completely satisfied, and (60 %) of patients not satisfied in Ibn-Sina teaching hospital.Than Al-Jamhory teaching hospital was (47 %) of patients completely satisfied, and (53 %) of patients not satisfied, while (42 %) of patients completely satisfied, and (58 %) of patients not satisfied in Al-Salam teaching hospital.At the end (49 %) of patients completely satisfied, and (51%) of patients not satisfied in Al-Kansaa teaching hospital

DISCUSSION
Nursing care is one of the major components of Health Care Services.Thus, patients have the right to expect quality of nursing care.Nursing staff, which comprise the vast majority of hospital staff, have the greatest contact with patients.Nurses, rather than physicians, are seen as responsible for the day-to-day activities on a unit.Nurses provide the main connection with patients, act as patient advocate with other care providers, give physical care to patients, and offer emotional support to both patients and families.Patients' satisfaction has been used as an indicator to measure the quality of health care provided by nurses (11) .Table (1) in present study shows age group among (21-30) years were (30.9%), but low percentage (10%) in age group (71-above years).With regard to the sex the highest percentage (61.7%)are female.The educational level of the present study, the highest percentage was (32.1%) who were the secondary school.While, the occupation shows highest percentage (58.1%) of the sample were housewives.Table (2) revealed that the highest percentage were (25.6%) for Ibn-Sina teaching hospital, and (68.7%) for number of nurses between (4-6 nurses) who give nursing care in the ward, and consisted majority percentage (82.3%)for the number of day stay in hospital between (1-5 days), and highest percentage (60.3%)were previous admission, while the highest percentage (68.2%)for patient not have other diseases in addition to the current disease.Table (3) in present study indicates a significant difference between mean patient satisfaction with nursing care and their age of patient, while shows no significant difference mean patient satisfaction with nursing care and their sex, occupation, and educational level by using ANOVA.Dorigan, and Guirardello study founded which (57.1%) were female with an average age of 52 (±) years old, most had completed primary school (61.9%) (12) .

Completely Satisfaction %
This table indicates a significant difference between mean score patient satisfaction with nursing care and their number of days staying in hospital, and patient previous admission to the hospital, but shows no significant difference between mean patient satisfaction with nursing care and their name of the hospital, number of the nurses in the ward, and if patient have other diseases in addition to the current disease by using analysis of variance.

Figure (1) distribution percentage of the patient completely satisfaction and not satisfied with the nursing care in the hospitals
This figure shows the level of patient satisfaction (40 %) of patients completely satisfied, and (60 %) of patients not satisfied in Ibn-Sina teaching hospital.Than Al-Jamhory teaching hospital was (47 %) of patients completely satisfied, and (53 %) of patients not satisfied, while (42 %) of patients completely satisfied, and (58 %) of patients not satisfied in Al-Salam teaching hospital.At the end (49 %) of patients completely satisfied, and (51%) of patients not satisfied in Al-Kansaa teaching hospital

DISCUSSION
Nursing care is one of the major components of Health Care Services.Thus, patients have the right to expect quality of nursing care.Nursing staff, which comprise the vast majority of hospital staff, have the greatest contact with patients.Nurses, rather than physicians, are seen as responsible for the day-to-day activities on a unit.Nurses provide the main connection with patients, act as patient advocate with other care providers, give physical care to patients, and offer emotional support to both patients and families.Patients' satisfaction has been used as an indicator to measure the quality of health care provided by nurses (11) .Table (1) in present study shows age group among (21-30) years were (30.9%), but low percentage (10%) in age group (71-above years).With regard to the sex the highest percentage (61.7%)are female.The educational level of the present study, the highest percentage was (32.1%) who were the secondary school.While, the occupation shows highest percentage (58.1%) of the sample were housewives.Table (2) revealed that the highest percentage were (25.6%) for Ibn-Sina teaching hospital, and (68.7%) for number of nurses between (4-6 nurses) who give nursing care in the ward, and consisted majority percentage (82.3%)for the number of day stay in hospital between (1-5 days), and highest percentage (60.3%)were previous admission, while the highest percentage (68.2%)for patient not have other diseases in addition to the current disease.Table (3) in present study indicates a significant difference between mean patient satisfaction with nursing care and their age of patient, while shows no significant difference mean patient satisfaction with nursing care and their sex, occupation, and educational level by using ANOVA.Dorigan, and Guirardello study founded which (57.1%) were female with an average age of 52 (±) years old, most had completed primary school (61.9%) (12) .
This table indicates a significant difference between mean score patient satisfaction with nursing care and their number of days staying in hospital, and patient previous admission to the hospital, but shows no significant difference between mean patient satisfaction with nursing care and their name of the hospital, number of the nurses in the ward, and if patient have other diseases in addition to the current disease by using analysis of variance.

Figure (1) distribution percentage of the patient completely satisfaction and not satisfied with the nursing care in the hospitals
This figure shows the level of patient satisfaction (40 %) of patients completely satisfied, and (60 %) of patients not satisfied in Ibn-Sina teaching hospital.Than Al-Jamhory teaching hospital was (47 %) of patients completely satisfied, and (53 %) of patients not satisfied, while (42 %) of patients completely satisfied, and (58 %) of patients not satisfied in Al-Salam teaching hospital.At the end (49 %) of patients completely satisfied, and (51%) of patients not satisfied in Al-Kansaa teaching hospital

DISCUSSION
Nursing care is one of the major components of Health Care Services.Thus, patients have the right to expect quality of nursing care.Nursing staff, which comprise the vast majority of hospital staff, have the greatest contact with patients.Nurses, rather than physicians, are seen as responsible for the day-to-day activities on a unit.Nurses provide the main connection with patients, act as patient advocate with other care providers, give physical care to patients, and offer emotional support to both patients and families.Patients' satisfaction has been used as an indicator to measure the quality of health care provided by nurses (11) .Table (1) in present study shows age group among (21-30) years were (30.9%), but low percentage (10%) in age group (71-above years).With regard to the sex the highest percentage (61.7%)are female.The educational level of the present study, the highest percentage was (32.1%) who were the secondary school.While, the occupation shows highest percentage (58.1%) of the sample were housewives.Table (2) revealed that the highest percentage were (25.6%) for Ibn-Sina teaching hospital, and (68.7%) for number of nurses between (4-6 nurses) who give nursing care in the ward, and consisted majority percentage (82.3%)for the number of day stay in hospital between (1-5 days), and highest percentage (60.3%)were previous admission, while the highest percentage (68.2%)for patient not have other diseases in addition to the current disease.Table (3) in present study indicates a significant difference between mean patient satisfaction with nursing care and their age of patient, while shows no significant difference mean patient satisfaction with nursing care and their sex, occupation, and educational level by using ANOVA.Dorigan, and Guirardello study founded which (57.1%) were female with an average age of 52 (±) years old, most had completed primary school (61.9%) (12) .
Data from this study pointed out that the level of satisfaction is increased according to patients' educational level, due to the better understanding of patients about the procedures to which they are subject.Such findings differ from those from other studies (13) .Sahin , Yilmaz , and Lee study shows the level of satisfaction is inversely proportional to patients' educational level, that is, the higher the schooling, the lower is the level of patient satisfaction (14) .Another study by Mohanan, Kaur, Das, and Bhalla indicated to no significant relationship between all the demographic variables and the patient satisfaction.However, a significant relationship between education of the patient and satisfaction of the patient with information given by nurses to his family and friends about patient's condition was found (15) .Maqsood, Oweis, and Hasna in their results of study also indicated that there were no significant relationships between patients' socio-demographic characteristics and satisfaction with nursing care (16) .Table (4) in our study indicates a significant difference between mean patient satisfaction with nursing care and their number of days staying in hospital, and patient previous admission to the hospital, but shows no significant difference between mean patient satisfaction with nursing care and their name of the hospital, number of the nurses in the ward, and if patient have other diseases by using ANOVA.Other study by Rahmqvist shows the length of stay is proved to be an aspect that directly influence on the patient satisfaction regarding the Professional domain.Those who were hospitalized for four to seven days reported a higher level of satisfaction than those who stayed within the unit for less than three days (17).Also Alhusban, and Abualrub in study showing that a long stay is related with a higher level of satisfaction and, although the author does not mention the reasons for such findings, this means that a longer time of hospitalization provides more opportunities to experience the dynamics of the unit, especially those concerning procedures and routines (18) .Figure (1) shows the level of patient satisfaction (40 %) of patients completely satisfied, and (60 %) of patients not satisfied in Ibn-Sina teaching hospital.Than Al-Jamhory teaching hospital was (47 %) of patients completely satisfied, and (53 %) of patients not Satisfied, while (42 %) of patients completely satisfied, and (58 %) of patients not satisfied in Al-Salam teaching hospital.At the end (49 %) of patients completely satisfied, while (51%) of patients not satisfied in Al-Kansaa teaching hospital.Mohanan, Kaur, Das, and Bhalla founded the patients were fairly satisfied with care and concern shown by nurses towards patients' (40%).A majority (80%) of the subjects considered 'nurses to be highly competent'.Subjects were somewhat dissatisfied as was noted in items of care such as consideration of their needs and provision for their privacy (15) .Maqsood, Oweis, and Hasna findings of this study showed that in general the patients were highly satisfied with overall quality of hospital care, nursing care and reported that they would recommend this hospital to their families and friends (16) .

CONCLUSIONS
The study found that common problem for hospitals which requires urgent attention to enhance patients' satisfaction at the same time to insure of nursing care.In addition the most of the patients are dissatisfied with the nursing care in hospitals, and patient satisfaction was influenced by the age of the patient and the days of stay in the hospital, also if patient has a previous admission to the hospital.

RECOMMENDATIONS
1.The nurses should improve the way of conveying information to all patients because that leads most patients to dissatisfaction.2. Development the communication skills between nurses and patient to providing high quality of care and completely patient satisfaction.3. Working to improve nursing care services by using guidelines in hospitals to measuring patient satisfaction.

Table ( 1) Distribution of the demographic characteristics of the study Demographic Characteristics Frequency Percentage
This table demonstrates demographic characteristics of the study sample shows the highest percentage (30.9%) of the sample were from the age group (21-30) years, but low percentage (10%) in age group (71-above years).With regard to the sex the highest percentage (61.7%)are female.The educational level of the present study, the highest percentage was (32.1%) who were the secondary school.While, the occupation shows highest percentage (58.1%) of the sample were housewives.

Table ( 3) Analysis of variance for the difference between mean score of patient's satisfaction with nursing care and their demographic characteristics
This table indicates a significant difference between mean score of patient satisfaction with nursing care and their age, while shows no significant difference mean score of patient satisfaction with nursing care and their sex, occupation, and educational level by using ANOVA.