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Health Care Quality

1.0 Background To The Study

The Client enters the health care delivery service with needs, concerns and expectations, requiring various interventions. Identifying and providing appropriate care to meet these needs in a cost effective way without compromising the standard of care is one of the challenges facing health care providers today.

Other challenges facing them include consumer’s demands, professional demand for excellence, high cost of healthcare and demographic shifts. In order to provide quality care that meets the client’s need and increase his satisfaction the client’s views must be respected and his preferences taken into consideration. Studies to identify clients’ preferences have shown that providing physical comfort adequate and timely information, coordinated and integrated care, emotional support, respect for clients’ values and rights are powerful predictors of client satisfaction (Gerteis, 1993; Potter and Perry, 2001).

Other studies also showed that irrespective of cultural background and beliefs, providers’ behavioural attributes such as showing respect, politeness, provision of privacy and reduction in clients’ waiting time influence clients’ satisfaction with care (Population Report, 1998).

Clients satisfied with the care they received have been found to pay compliments, comply with instructions, keep clinic appointments and recommend the hospital to friends and family members (Larson and Ferketich, 1993; Kotler and Armatrong, 1997, in contrast, those not satisfied have been found to complain, take legal actions, change providers or even leave the orthodox health care services for complementary therapies or alternate medicine (Luthert, 1990; World Bank Report, 2000; Jegede, 2001).

These activities have affected the health care delivery system. In recent times, several changes have also emerged. This includes a change in the stereotyped image of the patients. Historically the patient had been viewed as a passive recipient of healthcare in a paternalistic relationship with the caregiver. This is no longer the case, as today the client is a well-informed consumer with a strong negotiating power of choice, which he uses to his advantage (Melville, 1997, Alagba 2001).

This position was strengthened by the Consumers’ Bill of Rights of 1965 and the Patients’ Bill of Rights of 1975 (smelther and Bare, 2000, Alagba, 2001). The Bills emphasized Client satisfaction with services provided more so as satisfaction has been accepted as a major indicator of quality care. Furthermore, as consumer of the services the client is in the best position to say if a service has met his needs or not. The client’s perception of care is therefore of paramount importance to any provider.

However, in spite of all these, healthcare workers’ care alone may be inadequate to meet all the client’s needs. Client-centered care required that healthcare delivery system provide client-friendly hospital policies, adequate number of professionals, safe and clean environment, appropriate equipments and functional laboratories. These facilities provided at affordable prices are necessary to complement healthcare workers’ efforts and guarantee client’s satisfaction.

Unfortunately the major hindrance to the achievement of this goal is the high cost of healthcare services, for example, Stanhope and Lancaster (1996), Potter and Perry (2001) reported that there was a great hike in health care delivery system in United States of America.

Then the health care costs inflation was said to have been higher and faster than the consumer price index between 1950 – 1980, and in 1993 it was said to have increased twice above the national inflation index. This hyper inflation, Stanhope and Lancaster (1996) further stated led to consumers’ outcry and great demands for cost effective healthcare services.

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Chapter Two

Literature Review

Several authors have defined the word satisfaction severally, for example Webster’s dictionary defines satisfaction as “the fulfillment of a need or demand and the attainment of a desired end”. The Oxford Advanced Learner’s Dictionary defines it as “the feeling of contentment felt when one has or achieves what one needs or desires”. Satisfaction can also be simply defined as a sense of contentment emanating from perceived needs met.

These definitions suggest the need for needs identification and goal setting before satisfaction can be attained. It would also appear that satisfaction is subjective with only the individual attesting to his/her satisfaction. In today’s provider-client relationship the onus lies on the providers to strive at client satisfaction.

Studies to identify the antecedents of client satisfaction have shown that client satisfaction is one of the results of the provisions of good quality service; consequently it has become an important quality indicator (Filani, 2001; Vuori, 1987). The need to provide quality care is based on several factors including the principle of equity. Clients and consumers who pay for services are entitled to value for money paid.

Satisfaction is also found to depend on client’s expectations. Each individual has an expectation of the outcome of an interaction, a relationship or an exchange. Positive outcome engenders client satisfaction. This view is well articulated by Kotler and Armstrong (1997) who stated that “when a client’s expectations are not met, the client is dissatisfied, when it is met the client is satisfied and when it is exceeded, the client is delighted, and keeps coming back”. Consequently service providers should assess clients’ expectation at the inception of a relationship in order to consciously plan to satisfy the client.

Sometimes clients may not be sure of what to expect, it becomes necessary for service providers to develop an expectation of good quality in the client so that they can insist on it. Otherwise the client may be satisfied with relatively poor services (Shyer and Hossan, 1998).

This is not in the interest of the client or the service providers. Therefore counseling the client and informing the public on what constitutes appropriate care or service should be seen as efforts to develop and sustain client satisfaction. This is especially important in the light of current reforms in the health care delivery system.

Recently, certain forces have occasioned reforms in the healthcare delivery system; these forces include population demographics such as increasing number of the aging population, cultural diversity, changing patterns of disease, technology, economic changes and clients’ demand for quality care (Smeltzer and Bare, 2000). These forces demanded that care providers developed innovative ways to meet clients’ needs and increase clients’ satisfaction.

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Today healthcare is viewed as a product to be purchased and patients hitherto seen as passive recipients of healthcare have metamorphosed into empowered consumers. As consumers the clients command the attention of providers and healthcare managers who have a duty to ensure their satisfaction. This view was supported by the British Government when dealing with the National Health Service (NHS) inability to cope with problems increasing demand on it by the aging population, the advancements in medical technology and the rising expectations of healthcare users (Melville 1997).

Also like consumers it has been noted that healthcare clients are getting increasingly associated with rights, power and empowerment. Their present status enables them to take control of their circumstances and achieve their own goals. Adams (1990) observed that it also enables them to work towards the maximization of the quality of their lives. Using their power, clients demand for good quality healthcare: their demand is supported by the World Health Organization, Alma Ata declaration of 1978, and the constitution of the World Health Organisation (1966).

The latter, stated that, “good health is a right of all people”. This is interpreted to mean a right to availability, accessibility and affordability of good quality health care. It follows that healthcare should be provided in a way that is acceptable and satisfactory to the consumer, who also has the power of choice.

Literatures abound on the clients’ power of choice (Rogers, 1993, Melville 1997). However, suffice it to note that the client as a consumer uses this power to select between alternatives and chooses what gives him/her best satisfaction. This fact was also noted by Alagbe (2001), who citing the Law of marginal utility stated that “Consumers are rational and have the ability to measure the utility or satisfaction they derive from each commodity consumed, and given a total rationality consumers elect a combination of goods and services that will maximize their satisfaction”.

This stresses the fact that consumers choose what will give them maximum satisfaction. The power of choice has numerous benefits for clients, including the fact that the client is frequently consulted by the provider or producer (Melville 1997). This also creates a relationship of partnership rather than the paternalistic one that had characterized the healthcare delivery system.

The goal before all healthcare providers is to develop and maintain a client-centered service in order to provide quality service and ensure client satisfaction, more so as clients are becoming more knowledgeable and health conscious (Smeltzer and Bare 2000).

Their interest was stimulated and sustained by the television, internet, newspapers and magazines other communication media and by political debates. Their increasing demand for quality care based on this increase in knowledge was however catalyzed by the consumers’ awareness campaigns of the 1960s and 1970s, which subsequently led to the formulation of the Patients’ Bill of Right. This will be reviewed later following a review of the historical background of consumerism.

Historical background of consumerism

The early 1960’s saw the American public agitating for quality service for every dollar spent. Most business executives regarded the agitation as transitory threats. The consumerists however continued and became extremely vocal in their criticisms and protests against escalating cost of services without corresponding improvement in the quality of goods.

According to Alagbe (2001) in 1962, the American consumer movement received a major boost with a presentation to the congress of the consumers’ Bill of Rights; by President John F. Kennedy the bill contained four items namely, that the consumers should have:

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- The right to safety: This refers to protection against products hazardous to health and life.

- The right to be informed: This refers to protection against fraudulent, deceitful or misleading information in advertising or elsewhere and by also providing people with facts necessary to make informed choices.

- The right to choose: This refers to assurance of reasonable access where possible to a variety of products and services at competitive prices with government regulations to assure satisfaction, quality and service at fair prices.

- The right to be heard: This refers to the right of redress with the assurance that the consumer’s interest will receive full and sympathetic consideration by government’s expeditious actions.

Based on this the American Hospital Association in 1972 published a list of rights for hospitalized patients. The patients’ bill of rights was devised to inform patients about what they should expect from a caregiver-patient, and a hospital-patient relationship.

The patients’ bill rights

The patients’ Bill of Rights have strong implications for the healthcare worker, who is involved in independent, dependent and interdependent care of the patient. The care giver (Doctor, Nurse, Physiotherapist etc) form the most central and important part of the patients’ stay in the hospital. The care giver respecting patients’ right will ensure his satisfaction with care. Every healthcare worker therefore has a responsibility to ensure that the client’s right as enunciated by the Bill of Rights is always respected.

The bill includes that, a patient has the right to considerate and respectful care. This implies that health services providers should consider such facts as individual preferences, developmental needs, cultural and religious practices and age differences in their care of the patient. S/he also has the responsibility of ensuring that their assistants offer the same level of care.

The patient has the right to obtain from his physician, complete current information concerning his diagnosis, treatment and prognosis, in the terms that the patient can reasonably understand. When it is not medically advisable to give such information to the patient, the information should be made available to an appropriate and reliable person on his behalf. He has a right to know by name the physician, responsible for coordinating his care.

The patient has the right to receive from his physician the information to give informed consent. Some patients may not want to know everything about them, so the care giver has the responsibility to explain to the client that it is their right to know all, as it is a legal requirement. This helps the patient appreciate his responsibility for his health. The average client also appreciates the honesty of these explanations in the long run, because he is being treated as a partner with decision power.

The patient has the power to refuse treatment to the extent permitted by the law, and to be informed of the medical consequences of his action. It is difficult for healthcare workers to understand why clients refuse treatment that can benefit them, but this is a reality. Often, explaining in simple language the purpose solves the problem. If after the explanation of purpose and procedure, the patient still refuses, the care giver should remember that such action is the patients’ right. However, good planning of care that includes the patient in planning has tended to reduce the problem of refusing therapy.

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The patient has the right to consideration of his privacy. The patients’ right to privacy is readily violated on busy wards especially where there are no curtains as is the case in most government hospitals in many third-world nations because of the current economic crunch.

Healthcare workers as patients’ advocates should ensure that their rights to privacy are respected. Efforts to ensure clients privacy should include having discussions with clients conducted in private areas not at their bedsides for all to hear. Also patients’ conditions should not be discussed in the hearing of other patients. Class assignments must not identify a patient by name or position.

The patient has a right to expect all communications and records pertaining to his care to be treated as confidential. Patients’ charts should not be left to be read and discussed by unauthorized personnel. Laboratory result should be well documented and stored. Healthcare workers need to remind other aids that patients records are confidential and not to be discussed at home with friends and relatives.

The patient has a right to expect that within its capacity, a hospital must make reasonable response to the request of a patient for services. Nurses are often in charge of coordinating services for the patient such as x-rays, appointments with specialists, such as physiotherapist, etc. these should be available and provided in the order that is convenient for the patient. Also in the event of a transfer, the nurse should emphasize this to the reference hospital.

The client has the right to obtain information as to any relationship of his hospital to any other healthcare and educational institutions or hospital personnel. Sometimes hospitals are affiliated to or are owned by some religious organizations and universities; this has implications for the client care. He therefore has a right to be informed about it.

The patient has the right to be advised if the hospital proposes to engage in, or perform human experimentation affecting his care or treatment. He has the right to refuse to participate in such research projects. Most clinical trials take place without the clients’ knowledge, or even when explained the language may be too technical for the client to understand.

After explicit explanation, a client should be asked to sign a separate consent in addition to his consent for care if an experimental therapy is proposed to him. He can also withdraw at will without any reprisals. The patient has a right to refuse permission to any one to touch his body. His basic responsibility is to himself and not to the advancement of science or learning.

A patient has a right to expect reasonable continuity of care. Healthcare must to continuous and of the same quality. A change in shift should not result in negligence.

The patient has a right to examine and receive an explanation of his bill, regardless of the source of payment. In places where bills are paid by third parties and insurance, it is easy to assume that clients should not care about charges. The client has a right to receive explanations and demand for rational charges.

The patient has a right to know what hospital rules and regulations apply to his conduct as a patient. Some hospital rules are very restrictive, however, if they are written down and given to patients, the patients are more likely to remember them. Patients’ have the right to be properly informed; having the booklets to review at his leisure time and reminding them of these rules will help compliance.

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It is important that a client has access to the bill of rights as the consumer’s access to the bill of rights ensures that he is able to demand for his rights.

However as the patients’ advocate, the healthcare worker has a responsibility of ensuring that these rights are respected as provided. These rights ensure that the consumer/client’s basic needs are met. To guarantee this, Haskel and Brown (1998) recommended that hospitals should create a culture that focuses on patients.

This, they argued will allow health workers to respond to patients’ needs and even go beyond their expectations. The Health care system determines the quality or services provided. Unfortunately today, healthcare financing is more economy driven than patient-centered. (World Bank Report, 2000). This portends a danger for client care and needs to be examined.

This can be defined as the organ that organizes and funds health care services. Its goal is to provide an optional mix of access, quality and cost. Kielhorn and Schulenburg (2000) identified three basic models of health care system. These are the “Beveridge” model, the public-private mixed model and the private insurance model. The differentiating factor appears to be the funding and the coverage.

This is funded through taxation and usually covers everybody who wishes to participate in the state. Countries using this model include United Kingdom, Canada, Demark, Finland, Greece and Norway;

In this model healthcare budgets compete with other government spending priorities such as education, housing and defence. Consequently budget cuts and run away inflation lead to high costs of healthcare services. One of the resultant effects is shortage of healthcare professionals, like doctors, nurses, physiotherapists etc. Regrettably this is feared to have affected the quality of healthcare.

For example, Ferlman (2000), after a poll conducted on 2,000 adults for the British medical association reported that, the number of people satisfied with the health service dropped to 58% as compared with 72% percent in 1998. The population who were “very dissatisfied” or “fairly dissatisfied rose from 17 percent to 28 percent This result may not be unconnected to the decline in the quality of healthcare services.

This model is funded primarily by a premium-financed social mandatory insurance, it has a mix of private and public providers, which allows for more flexible spending on healthcare. (Kielhorn and Schulenburg, 2000). Participants are expected to pay insurance premium into competing non-profit funds and the physicians and hospital are paid through negotiated contracts.

The funds can also be supplemented through additional voluntary payments. Countries that use this model according to Kielhorn and Schulenburg (2000) include France, Germany, Australia, Switzerland and Japan.

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This model exists exclusively in its pure form in the United State of America (USA). Healthcare there is funded through premium paid into private insurance companies. The health insurance is not mandatory, so most often people with low income and high-anticipated healthcare cost, like people with chronic diseases are often unable to afford insurance.

This makes healthcare in this system selective and non-equitable. An estimated 15% of the population in USA where this model is practiced are said to be unable to have any insurance cover. (Kielhorn and Schulenburg, 2000).

Any of these three basic healthcare funding models are utilized by most healthcare organizations to fund the healthcare delivery system. However due to the global changes occasioned by various factors healthcare organizational developments became necessary, in order to contain costs and ensure quality care. (Stanhope and Lancaster 1996: Yoderwise, 1999).

The United Kingdom Health System

In a bid to provide free healthcare services for all UK residents, National Health Service (NHS) was founded in 1948. Funds for running the NHS was got through general taxation and this fund is administered by the department of health. Essentially, consumers of healthcare services do not pay at the point of receiving the services.

Apart from the NHS, Private healthcare providers also exist in the UK but the consumers of their services either pay at the point of service or through insurance.

The NHS: Considerable changes have occurred in the structure of the NHS over time. There is however no considerable differences in the structure and functions of the NHS among the countries which make up the UK. In England for example, the department of health in collaboration with other regional bodies or agencies take charge of the overall strategy while the local branch of a particular NHS takes the key decisions about local healthcare.

The secretary of state for health is the minister overseeing the NHS and he reports to or is accountable to the Parliament. The overall healthcare management is the duty of the department of health, which formulates and decides the direction of healthcare.

England has about 28 strategic health authorities which are concerned with the healthcare of their regions. They are the intermediary between the NHS and Department of health.

Types of trusts

Local NHS are called Trusts and they provide primary and secondary healthcare. England has about 300 Primary care trusts and these altogether receive ¾ of the total NHS budget.

NHS Trusts: these are responsible for specialized patient care and services. They run most hospitals in the UK. There are different types of NHS trust:

- Acute trusts providing short term care e.g. accident and emergency care, maternity, x-rays and surgeries etc; Care trusts; mental health trusts and ambulance trusts.

Foundation trusts: ownership of these trusts is by the local community, employees, local residents. Patients here have more power to shape their healthcare based on their perceived health needs to their satisfaction.

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Private Healthcare

This sub-sector of the UK healthcare system is not as big as the NHS and does not enjoy similar structure of accountability as the NHS. They may be similar to the NHS in service provision but are not bound to follow any national treatment guideline and are not saddled with responsibility of the healthcare of the larger community.

Regulation and inspection of healthcare system in the UK are carried out by a number of designated bodies. Some of these are the national institute for clinical excellence; the healthcare commission; the commission for social care inspection and the national patients’ safety agency.

Community Satisfaction with Healthcare System

World Bank (2000) identified three basic types of healthcare organizations providers in the healthcare system. These are: the market or for profit co-operations, the government, and the not for-profit organizations. The last group includes the mission hospitals run by religious and non-governmental organizations. For them their main objective is to provide quality care for the citizens. Although scarce resources often limit their efforts, they are reported to be providing quality care to clients within their means. (World Report, 2000).

In Government run systems especially in many resource-constrained nations, the main complaint is the failure of the Government run systems, which are supposed to be the most equitable and cheapest system for providing care, is being run down for ideological reasons in some countries, (World Bank, 2000). This jeopardizes the availability of healthcare services to the individual, resulting in the client’s non-satisfaction with one.

Lastly, are the for-profit co-operations. These, according to World Bank (2000) have problems of care and affordability, which parallel their profit. The affordability is noted to be most acute in the market-listed companies. This is because the prime objective of these groups entering the health market is to make profit from the sickness the most costly and least affordable healthcare providers. Unfortunately while share holders are getting profit the clients for whom health care is provided are receiving poor quality care.

World Report (2000) documented declining care and increasing dissatisfaction with healthcare in most countries. The greatest dissatisfaction was reported in the market-based systems and when market placed systems replaced state funded ones.

The market system in the USA, which was supposed to help the citizens, is criticized for deliberately exploiting them. Critics argued that the strong competitive measures encouraged, have destroyed the ethics of USA’s hospitals’ Samaritan culture and the professionals of the healthcare providers.

Patients were reported to have had to suffer as a result. Equity was also said to have become a problem, as healthcare is no more available to all citizens. This was attributed to the effect of the market systems on the health care delivery service.

The market based systems are also reported to have wide spread incidences of denial of care of patients, mis-use of patients for profit and neglect of the frail and vulnerable (World Bank, 2000). These were said to have occurred when profits were being earned and shared by corporate bodies to shareholders. Information from the market place were said to have revealed receptive marketing, and mis-information which covered up the misdeeds of the corporate bodies.

In response proponents of the market system defended their policies and argued for its usefulness, and value in healthcare reforms. For examples Samuel (2000) argued that competition, a fall out of the market system encourages efficiency, reduces costs, enhances responses to consumer demands and favours innovations.

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Consumer empowerment, he stressed is one of the dividends of competitive healthcare systems. He added that introducing competition would provide consumers the freedom to choose between different services and different delivery mechanisms that meet their needs. It is also expected that this would increase their satisaction.

Competitive pressures, Samuel (2000) pointed out will break down self-regulatory practices by service providers, developed essentially to serve their interest, so that clients interest will eventually be served. While the above argument is appreciated, it is also observed that the problem of equity is more profound here, as it appears that only the few that can afford quality care can get it. In the light of the what Alma Ata declaration of 1978, all nations have a responsibility and an obligation to attend to the health needs of all their citizens.

It is obligatory to make healthcare available, accessible, affordable and acceptance to all. These places on the government of every nation the responsibility to ensure that there is equity in health care services distribution. In order to ensure this, countries like the United Kingdom entirely funded the National Health Service (Kielhorn and Schulenburg, 2000). As a result, even in the face of health care cuts and shortages the NHS clients were found to be very supportive of the system. (Walsh, 1999).

In most other countries, clients have reacted to the healthcare system and services provided in various ways. In some places, they have responded with an observable move away from conventional medical care. This trend, most argue, can be traced to the high cost of the latter.

There is also the argument that clients’ expectations are no longer met through conventional healthcare services. This is said to be so especially for clients with less serious disorders. For example, Manga (1993) found that clients were considerably less satisfied with medical physician’s management of their low back pain than chiropractic management of the same ailment. These observations, were also corroborated by Cherkin and Maccomak, (1989) and Harris Poll, (1994).

Processes of a health service system

The processes of a healthcare service system refer to the actual performance of the activities of care. Stanfeld (1992) identified two components of the processes. These are the activities of the providers of care and the activities of the population.

Activities of health care providers

Every interaction between an individual or community and a care provider begins with need or problem identification. Starfield (1992) stated that the problem recognition implies an awareness of the existence of situations requiring attention in a health context.

Diagnosis, planning and intervention follows after that assessment, is carried out. Evaluation is done intermittently and the end of the intervention to determine if the original diagnosis, plan and interventions were appropriate and adequate for the recognized need.

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In nursing, models of care such as the nursing process are utilized to facilitate systematic and scientific provision of quality care and client satisfaction. Also care provided is guided by established institutional standards of care. Effective assessment of client’s needs and its resolution is expected to have an outcome of client satisfaction. It is therefore important that the healthcare provider’ intervention should be client centered, in order to achieve the set goal.

Activities of the client

People decide whether or not, and when to use the health care system (Starfield 1992). It is in coming in contact with the health care system that clients recognize what services are offered and the quality of the services offered. The clients’ experiences enable them to form their opinions, deciding if they are satisfied or not (Starfield 1992).

The caring process involves the performance of the activities of caring especially by health care professionals. The quality and number of personnel forms of the components of the healthcare delivery system and determines the outcome of care and clients’ satisfaction.

However, this can only be effective and achieve client satisfaction if the infrastructure in the system is adequate and the healthcare team is cohesive with their activities well coordinated. The relationships between the clients and the healthcare professionals, as well as the relationship among the healthcare team, have been found to affect the client’s evaluation of his/her hospital experience (Walsh and Walsh, 1998). So it will be necessary at this point to review the healthcare team and their various relationships.

Healthcare team

The healthcare team is made up of many professionals according to potter and Perry (2001). There are four general types of professionals including, nurses, physicians, allied health professionals (therapists and technicians) and other specialists such as social workers and chaplains. This multi professional team collaborates to provide quality care to clients. An understanding of each other’s role, communication among them, use of common language and value of each other’s perspective, are necessary to enhance cohesion among them (Midland and Jeffers, 2001).

Professional distinctness though present should enhance and not threaten the interdisciplinary team in the healthcare services. The patient is the focus of care and healthcare professional serve to provide them the best possible care.

The involvement of many persons in the clients’ health portends a danger of fragmentation of the care unless properly coordinated. The role of the coordinator of care is very important as it ensures continuity of care, which is one of the client’s expectations.

Ethics of caring

Ethics refers to the ideas of right and wrong behaviour, while caring, has been interpreted by some to mean moral responsibility. This is because through caring human dignity is protected, enhanced and preserved.

Potter and Perry (2001) citing Watson (1988) stated that caring is a moral ideal, which provides the stance from which nurses give their interventions. So in a healthcare worker/ client relationship, the healthcare worker must know and practice what is ethically correct. Traditionally, ethnical uprightness was based on standards of practice and ethical guidelines of beneficence, nonmaleficence, justice and autonomy of which caring is an integral part.

According to Potter and Perry (2001) the uniqueness of ethics of care is that it is not based on intellectual reasoning or analytical principles, rather, ethical decision making in care places the care of the client as the central issue. Decisions based on what serves the clients’ best interest signify putting the patient first. This, according to Garteis (1993) is one of client’s expectations of healthcare professionals.

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Ethics of care is concerned with relationship between people. This reflects on one’s character and attitude towards others. Cooper (1991) suggested that practitioners who function from an ethics of care are sensitive to unequal relationship with health professionals, because of their illness, lack of information, regression caused by pain, suffering and the unfamiliar circumstances. Therefore it is important for the care giver to use the ethics of caring, as using the ethic of care would place the care giver as the patient’s advocate rather than an abuser of the unequal relationship.

Having considered the concept and ethnics of caring, it will be pertinent to discuss the clients’ perception of caring.

Clients’ perception of caring

The study of clients’ perception of caring has become an important aspect of healthcare. This is because it is necessary to determine what clients perceive as caring and the best approach to provide caring to clients in order to ensure and increase clients’ satisfaction.

Emphasis on clients’ satisfaction is based on findings that clients’ experiences and thoughts about healthcare services determine their utilization of such services and the benefits they derive from it. For example, in a study of healthcare facility utilization, Mersch, Fisher, Askew and Ajayi (1994) found that 40% of the women in a study group in Nigeria did not attend the clinics nearest to them. The main reason given for their action was that the distant clinics provided better services. This finding supported Gerteis (1993) finding that, clients’ experiences and perceived benefits from a healthcare facility determine their utilization of the facility.

Swanson’s theory of caring (1991) according to Potter and Perry (2001) provides an understanding into the behaviours and processes that characterize caring for the clients. These behaviours include maintaining a reassuring presence, recognizing the uniqueness of the individual client, listening to him/her and keeping a close eye on the client. These findings reflect the affective dimensions and underscore William (1997)’s findings that although clients value nurses task performance, they also appreciate the affective dimensions of nursing.

It is therefore important for the professional healthcare provider to identify individual clients’ expectation of care. Building a relationship with the client in order to know him/her can help to achieve this. Also building a caring relationship with the client will enhance the healthcare worker’s opportunity of obtaining accurate knowledge of clients’ perception of care. In relation to that, Williams (1997) found that when clients sense that healthcare providers are interested in them as people they perceive their healthcare experience as satisfactory and are more willing to follow recommendations and therapeutic plans.

The existence of differences between healthcare providers and clients’ perception of care noted in literatures underscores the reasons for former to learn what is important to the later and what the later (clients) expect from the former(healthcare providers). This will be explored as we examine the client centred care.

Client-centered care

Many studies have identified cleints’ expectations of nursing: one of such is the Picker/Commonwealth Program for patient centered care carried out by Gerteis and others in 1993 (Potter and Perry 2001).

The purpose of the study was to identify and explore client’s needs and concerns as defined by the clients themselves. Promoting models of care that considered the needs and concerns expressed by the clients themselves and planning individualized care for each client is expected to help in achieving set goals and increasing client’s satisfaction. After interviewing hundreds of clients and their families, seven broad dimensions of care were identified. The dimensions of care identified describe clients’ expectations from caregivers especially from the nurses, these include:

Respect for Client’s Values, Preferences and Expressed Needs:

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A value is a personal belief about the worth of a given idea, attitude, custom or object that sets standards and also influences behaviours (Potter and Perry, 2001). Each individual has his values and the clients’ values influence their decisions to seek healthcare services, the choice of which healthcare facility to patronize, and their expectations from the caregivers (Yoderwise, 1999). Clients’ values are often reflected in their cultural beliefs and social behaviours, (Potter and Perry, 2001).

Respect for clients’ values and preference ensure that they are treated as individuals and facilitate decision making while ensuring the client’s autonomy. Also respect for the clients’ individual needs involves listening to him/her in order to determine his/her needs. Non-labeling of clients and a respect for their physical, social and informational privacy is also important.

Jointly assessing, planning, implementing and evaluating client’s care with them ensures that the clients’ perception of needs are not completely different from those identified by the caregivers (Pop. Report, 1997). The existence of differences between care givers’ and clients’ perception of care often noted in literature (Williams 1999) are results of incongruent perception of clients’ needs and preferences by healthcare professionals. Explaining and teaching the clients would minimize the risk of incongruent perception of needs since values, preferences, and needs have been known to change as more relevant information is gained (Pop Report, 1997).

In addition Gerteis et al (1993) also found that clients expect to be treated with dignity and respect. This emphasizes the need always seek their views in order to increase their satisfaction with care.

Coordination and Integration of Care

This refers to the fact that clients expect a competent and caring staff to take care of them. (Gerteis 1993) Wallence, Robertson, Millar and Friseh (2000) found that clients’ satisfaction with care and their appraisal of quality of care were based on their perception of the staffs’ competence. This they also interpreted as the staffs’ ability to deliver coordinated and continuous care.

Clients look for some one to be in charge of their care and to communicate dearly with other healthcare team members. This role has traditionally fallen on the nurses who often relate with clients and other team members (Potter and Perry 2001). With a coordinator clients are sure of who to call for help at all times.

Coordinated care is necessary to reduce bureaucracy (Larson and Ferketich, 1993) and an integrated care system reduces duplication of services and coordinates care across the care setting, ensuring that clients receive the most appropriate and cost effective care. These all promotes clients’ sense of well being and satisfaction with care (Starfied 1992).

Provision of Information, Communication and Education

Communication is a therapeutic skill required in healthcare practice. It is a process through which care givers affect clients and others by the exchange of ideas, information and feelings (Potter and Perry 2001). Clients expect to receive accurate and timely information about their clinical status, progress and prognosis.

Nordgen and Fridlung (2001) found that clients who feel they have been deprived of information express powerlessness and lack of self-determination. Clients’ information needs include changes in therapies, results of tests and procedures, hospital policies etc. With regards to care, clients and their families want to be taught how to manage care on their own to the extent that they desire and are able (Gerteis 1993).

Information should be given to clients in the language they understand. This is necessary because during illness patients of all ages have been found to regress and the regression often involves language skills (Smeltzer and Baare 2000). Another reason for that is to ensure clients’ understanding and subsequent compliance with treatment. (Potter and Perry 2001).

Many authors have found a relationship between clients’ dissatisfaction with care and a lack of effective communication by caregivers (Walsh and Wash, 1999; Tyson and Turner, 1999 and John, 1997). Tyson and Turner (1999) stated that 33% of their clients cited lack of information as reasons for dissatisfaction with care. Similarly John (1997) found that 67.8% of the respondents in a group studied indicated they were not satisfied with the way information and teachings were delivered.

Also, many nursing studies have noted the need for education, effective communication and provision of adequate information to clients by nurses. The contributors include Wash and Walsh (1999) who noted that adequate teachings and providing information empowers the client, relieves the clients’ fears and anxiety and exonerate the nurses and other care givers cases of litigations.

Provision of Physical Comfort

Comfort is a concept central to nursing Donalve (1989) reports that many nursing theorists refer to comfort as a basic client need for which nursing measure is delivered. Potter and Perry (2001) added that through comfort and comfort measures nurses provide strength, hope, support, encouragement and solace to clients.

With regards to providing comfort, clients expect that nurses should respond in a timely and effective way to any request for pain medication. Clients also expect explanations to the extent of pain they should expect and offers of any alternatives for pain management (Gerteis et al, 1993). Clients also expect privacy, clean, comfortable healthcare environment and settings where their cultural values can be respected. (Potter and Perry, 2001).

Health professional’s ability to provide comfort is a basic function, which provides the necessary milieu for clients healing to take place. Making the client comfortable enables him/her to solve his/her problems positively and also achieve set goals of recovery.

Provision of Emotional Support and Relief of Fear and Anxiety

Clients sometimes like to understand the meaning of their illness and the impact the illness will have on their ability to care for themselves and their family, so they look to care providers to share their fears and concerns (Gerteis 1993; Potter and Perry, 2001). Making time to listen to clients and explaining the course of their illness as well as providing information that will enable the clients manage side effects of treatment often ameliorate their anxieties and fears. Northeuse, Schafer, Tipton and Metiver, (1999) also found that encouraging clients to ask questions about unclear matters have been observed to help relieve their anxiety and enhance their satisfaction with the quality of care provided, (Leinoren, Leino-Kulpl, Stahl-bing and Lentotala 2001).

Nurses’ failure to meet client’s emotional support needs have been a long time concern of nurse leaders as found by John (1997) who noted that most often nurses concentrate on meeting clients’ physical needs for care without much attention to their psychological needs. This is in spite of the fact that, literature have shown that meeting clients’ psychological needs enhances the clients’ self esteem, self-actualization and gives them a sense of belonging (John 1997). In support, Tyson and Tuner (1999) found that lack of emotional support increased clients’ fears and anxieties and made them generally dissatisfied with care provided.

Most clients also worry about their ability to pay their medical bills, (Gerteis, 1993) and they expect healthcare workers to help with these worries by linking them to available resources or support groups that can help.

Involvement of Family and Friends

Clients rely on family and friends for support so they expect care providers to recognize and respect their families and friends (Gerteis, 1997). They also expect that the caregivers should properly inform the members of their family and friends who will provide physical support and care for them after discharge.

Family members serve as very important resource persons, they know the clients and most of them had been their caregivers prior to hospitalization. In view of that, Wallance Robertson, Miller and Friseh (2001) found that family members felt they should always be consulted in clients’ care because they often have important and useful information about the clients to share. Similarly, Northouse, Schafer, Tipton and Metriver (1999) also found that spouses of hospitalized patients wanted to be included in the health assessment and teachings of their admitted relatives. Besides the above-mentioned reasons, the spouses argued that getting better informed would relieve their fears and anxieties as they often regard the illness more negatively than the patients.

The role of family and friends to clients’ well being cannot be under estimated, in view of that, Smeitzer and Baare (2000) suggested that policies that promote culturally congruent care should establish flexible regulations pertaining to visitors especially with particular reference to number of visitors and length of visits.

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Transition and Continuity

Gerteis (1993) found that clients want information about medications to take, dietary or treatment plans to follow, danger signals to look for after hospitalization and treatment to be provided prior to discharge.

They also expect to have their continuing healthcare needs met after discharge with well coordinated services. The clients and their family members also expect access to any necessary healthcare resources after discharge (Gerteis et al, 1993).

As a result of developing disabilities, progression of chronic diseases or permanent impairment from injuries, clients often have long-term healthcare needs. While hospitalized, physiotherapists and other caregivers meet these needs, however, clients become anxious prior to discharge because of the uncertainly of the future. Leucknotte (2000) suggested that for such clients, continuing care may be provided within institutional settings (nursing homes) communities (adults day care) or at home.

So hospitals/ healthcare professionals need to provide clients with information on available facilities and support systems in their communities. The clients may not ask questions because they are not aware of the existence of such facilities however they expect caregivers to tell them if available. They also expect healthcare professionals to help them plan for continued care and easy transition from one care facility to another requires a coordinator and nurses who collaborate with every member of the healthcare team and are in every healthcare facility usually assume that role.

A well coordinated care ensures clients’ smooth transition from an in-patient to an out-patient status and also ensures that the appropriate team of doctors and therapists see the clients at follow up visits. This engenders clients’ feeling of safety and satisfaction.

Cleints’ medical records should be kept up to date since they expect that the status of problems noted in previous visits should be ascertained at subsequent visits (Starfield 1992).

Quality Care and Client Satisfaction.

Offering good quality care has always been the goal of every health care facility. However good quality care occurs when every member of staff at every level believes that quality is important and takes responsibility for it. What then is good quality care? Several people depending on the area of interest have defined this severally. Bluefield (1993) recorded that W. Edwards Deming a pioneer in the quality movement in the industries defined quality simply as “doing the right things right.”

In the healthcare service, quality could then mean offering technically competent, effective and safe care that contributes to an individual’s well being. Newrander and Rosenthal (1997) added other key elements of quality care, cost, efficiency and outcome. The World Health Organization (WHO) definition of quality encompasses all the above, it states that: “Quality of healthcare consist of the proper performance (according to standards) of interventions that are known to be safe, affordable to the society in question, and that have the ability to produce an impact on mortality, morbidity, disability and malnutrition” (WHO 1988).

The WHO definition underscores the need to have standards in order to compare performance to determine whether it is of a good or poor quality. In the absence of a standard or criteria of excellence, quality care would be difficult to measure.

Research have shown that what clients define as quality healthcare may not be what healthcare professionals define as quality care however client’s behaviour can be used as a crude litmus test for quality care. Clients’ satisfaction is an accepted important result of good quality care, so it is a good indicator of the quality of care (Carr-Hill 1992, Vuori 1987). Studies also showed that when the quality of a product or service satisfies a customer, he returns and also recommend the produce or service to others (Kotler and Amstrony 1997: WHO 1996).

In contrast, dissatisfaction and poor quality care leads to migration of clients to other clinics or providers. For example, in a study by Mensch, Fisher, Askew ad Ajayi (1994) in Nigeria, the authors found that nearly 40% of their subjects, said they did not use the Clinics closest to them rather they went to clinics further away. 90% of the women gave better services at the distant clinics as the reason for their choices. Similarly, Figueroa, Golcohea Poppe, Queirolo, Jappia and Tello (1997) reported that rural women in Peru switched from public to private sector providers for better care. This shows that clients want quality service and are ready to move around until they are satisfied with the care they receive.

How do clients judge quality of health care services? Studies have shown that Clients both in developed and developing Countries share some common views as to what constitute quality. These are: respect for clients (Schuler, Choque and Ramsel, 1994), understanding their situation and needs (Schuler, Hashemi and Jenkins, 1995), provision of complete accurate information. (Survey research Indonesia, 1996), and technical competence, Verot 1993) others include access, (United Nations 1995), fairness (Barrett and Stein, 1998) and results (Ndhlovu 1995).

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A client centered care is a vital guide to improving the quality of healthcare. Planners, managers and providers can design and offer services that both meet medical standards and treat clients, as they want to be treated. (Pop. Report 1998) it will be easy to satisfy clients’ needs for some other aspects of quality such as respect, provision of relevant information, access and fairness (Morgan and Mugatroyd 1994, Vea, 1993, Barret and Stein 1998) if care is client centered.

Health care providers have an ethical obligation to provide good quality service. Several practical benefits of good quality health care based on studies include,

It is important to note that both clients and providers’ satisfaction are outcomes of good quality service. Huezo (1998) reported that in Uganda, both Clinic and Community-based family planning providers agreed that the most satisfying aspect of their job was helping people and the Community.

The recognition they received for their job was also gratifying. Kin contrast Van Bergen (1995) observed that health personnel become discouraged and resort to putting most of their efforts into other jobs when working conditions prevented them from giving good quality care. In another study of good quality care and client satisfaction, Lauro (1998) reported that when women were counseled on how to use a therapy and its side effects, better client’s satisfaction was observed. As a result only 11% of women who received good counseling discontinued the method compared to 42% of women who received limited counseling.

Quality of care is also closely linked to accessibility (WHO 1988). So when a health care facility lacks properly trained staff, suffers from supply shortages, charges high fees, or care with unnecessary barriers, the clients do not have adequate access to the service. Their expectations become unfulfilled and they show signs and symptoms of dissatisfaction. Providing quality care in any healthcare facility would therefore depend on how well an organization meets client’s needs and expectations.

Clients’ Expectations of Health Care Givers

Webster’s third new international dictionary defines expectations as the action of looking forward to or waiting for something. Expectation also refers to a belief that something will happen. This implies a prior conceptualization of the expected. Clients’ expectation can therefore be viewed as clients’ desire or needs prior to seeking the caregivers.

If the outcome of care or performance matches the patients’ expectations, he/she will invariably be satisfied. Most often the motivation to seek healthcare providers are largely due to the clients’ expectation and his perception of his/her illness influences the content of his/her expectations (Staniszewska and Ahmed, 1999).

In the healthcare services expectations can also be viewed as client’s desire to recover his original health status. This definition points to the fact that one of the motivations to seek care providers is the client’s belief that caregivers can assist him or her to get well without much loss. Therefore clients’ needs and expectations should be a priority for caregivers.

The need to determine client’s expectations at first contact with healthcare clients was identified by Potter and Perry (2001) who stated that assessment of client’s expectation should be a routine when client first enters a healthcare setting.

Understanding client’s expectations of the healthcare service is expected to help caregivers plan individualistic care that will increase the clients’ satisfaction (Gerteis 1993; Pop, Rep; 1998) Client satisfaction is influenced by providers ability to meet or exceed the clients expectation, consequently, client expectations is viewed as an important measure of the evaluation of healthcare (Potter and Perry 2001).

Characteristics and types of client’s expectations

Client’s expectations were found to have some characteristics. Staniszewska and Ahmed (1999) found that the content of client’s expectation was influenced by their illness and that expectations varied according to prevailing circumstances. And also that client distinguished between realistic and idealistic expectations.

For example a study of NHS patients showed that the patients were aware of the political and economic constraints under which the British healthcare system operated at a particular time, consequently they expected long waiting hours and cut back in health care provisions. (Staniszewski and Ahmed 1999).

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Clients have also been found to have high or low expectations of healthcare service and this can have an effect on the quality of care provided. Therefore healthcare providers have a responsibility of educating clients in order to raise their expectations so that the clients can demand for quality healthcare service. (Pop. Report, 1999).

Types of clients expectations

Different forms of expectations have been found in the literature. Thompson and Surol (1995), Stanizewska and Ahmed (1999) identified the following forms to expectations as they relate to healthcare clients.

Predicted expectations

This refers to a realistic, practical or anticipated outcome of interaction. This type of expectation expressed what an individual thinks will happen during the encounter with the healthcare services. The patients past experiences and other sources of information may influence it. (Kotler and Armstrong 1997). For example, the patients will expect to get well after his treatment.

Normative expectations

This refers to what is desired (Staniszewka and Ahmed 1999) that is, what should be, for example. “The nurse should give me my injection on time.” Such a feeling of deserving has some elements of equity. The patient expects it as a right knowing also that the healthcare providers can give it. Normative expectations have been proposed as an important contribution to healthcare evaluations (Staniszewska and Ahmed 1999).

Unformed or party formed expectations

This type is said to occur when the clients have no prior experience of any particular form of care or they are unsure about aspects of their care. Usually while patients are not sure of what to expect from doctors and nurses, their expectations of their own participation are partly formed. This is probably because they have no personal experience of participating in their care (Staniszewska and Ahmed 1999). Healthcare workers have the responsibility to plan client’s care with them delineating clearly people’s role.

Positive and negative expectation

This was identified by Staniszewska and Ahmed (1999). They noted that clients have positive expectations, which can be expressed, as “doctor will examine regularly”. Sometimes the clients also acknowledge lapses in some aspects of care and even accept them. For example they expect doctors and nurses to make mistakes.

While these are expectation, they are nevertheless negative ones. In order to avoid this, physiotherapists and other healthcare providers need to make care client-centered for as clients participate in their care, their expectations are fulfilled and their satisfaction is usually ensured.

Client Satisfaction

Client satisfaction, a topical issue in healthcare services became necessary because of the need to make healthcare client centered and of a high quality. Customer satisfactions services have always been an integral part of any industry. The emphasis became necessary when customer satisfaction was found to depend on a product’s perceived performance in delivering value to a buyer’s expectations (Kotler and Armstrong 1997).

So in the industries as well as in the healthcare services client satisfaction has became an important indicator of quality care (Filani 2001: Kotler and Armstrong 1997). It is also an expected outcome of care in the healthcare services (Pop Report 1997).

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Many authors have argued as to what actually leads to client’s satisfaction? This is based on the observations that it could have both internal and external antecedents. The external factors identified as having effect on clients’ satisfaction include:

On the other hand, one of the identified internal factors was the clients’ personal characteristic of self-esteem (Latham 1996). In a study of Folkman and Lazarus cited by Latham (1996), it was observed that when self-esteem, as a variable was combined with cognitive appraisals and coping strategies in a study of 150 middle aged community residents, the clients’ personal characteristics of self esteem was found to account for a significant portion of the variance in psychological symptoms and satisfaction.

Also it was observed that when information about hospital experiences, invasive hospital procedures and coping strategies were not provided, the clients’ psychological distress and dissatisfaction increased and clients felt powerless (Latham 1996).

The general effects of client satisfaction on client’s health outcome were identified as better post-operative adaptation, higher rate of recovery, earlier discharge rates, and better level of compliance with medications (Latham 1996). Haskel land Brown (1998) added that satisfied clients experience decreased psychological distress, which releases their energy to concentrate on healing.

The behavioural outcomes of client satisfaction are also of great interest to providers. In that regards Pop. Report (1996) reported that there were benefits associated with satisfying healthcare clients. It was stated that satisfaction with healthcare services has the ability to influence client’s behaviours as to

Therefore in spite of the professional and ethical reasons for ensuring client satisfaction, the benefits can be said to justify the efforts made in that direction.

Although great interests have been stimulated in client satisfaction studies because of its importance, the results of most of them according to Larson and Ferketich (1993) Staniszewska Ahmed (1999) and Walsh and Walsh (1999) have consistently shown a high level of client satisfaction with healthcare. However, some researchers are questioning the accuracy of most of the results. For example, like Aharony and Strasser (1993) questioned the validity of the instruments used in measuring client satisfaction.

They also argued that the ambiguity surrounding the definition of the concept of satisfaction and the lack of a suitable conceptual frame work posed legitimate problems Baker and Whitefield (1992) also questioned the consistent high levels of satisfaction with care responses from clients as according to them “healthcare professionals have not always claimed to provide perfect caring at all times”. In the same vein, Anderson (1981) and Drew (1986) observed that non-caring was still being perceived by hospitalized patients.

These findings may be explained by Rosenberg (1996) observation that people respond positively to the word “satisfied”. Similarly Calla (1991) also observed that some cultural norms against complaining sometimes contributed to client’s positive responses.

Therefore healthcare providers need to establish a trusting caring relationship with the clients in order to determine the accurate quality of care they provide. This is at the backdrop of the warning contained in Pop. Report (1997) that clients’ satisfaction as shown in some interviews and surveys may not necessarily mean that the quality of care was good, rather, sometimes, clients merely claimed they were satisfied because they wanted to please the interviewers or they were afraid care might be withheld in future (Mawajdah, At – Qutob and Bin Road, 1996).

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The need to have an accurate assessment of the situation in many healthcare facilities have led to the suggestion that health care providers should embrace client dissatisfaction rather than satisfaction studies.

Client Dissatisfaction with care

Dissatisfaction can be defined as a complex social construct, which is underpinned by a range of values, beliefs, attitudes and experiences. Coyle (1999) observed that most clients were actually dissatisfied with healthcare services, and that underpinning the clients’ accounts of negative experiences of healthcare are fears of their loss of personal identity. He claimed that clients’ experiences with the healthcare providers showed that clients felt dehumanized, objectified, stereotyped, disempowered and devalued.

He went further to strongly support client’s dissatisfaction studies because of the effect of dissatisfaction on the practitioner-client’s relationship and on health related behaviour. This supported by Tucker, Bolton, Oslon and Williams (1985) findings that previous dissatisfaction with communication or attitude of healthcare practitioners constrained the mutual sharing of information and understanding in subsequent medical encounter.

Women were found to have the propensity for complaining more than men (Coyle, 1999). Nettleton & Harding (1994), explained that most often the women saw it as a moral duty to complain if they felt something was wrong and often complained on behalf of others. This could be related to their roles as care givers or nurturers.

The clients dissatisfaction with care was found to be heightened by what they perceived as the uncaring attitudes of health service managers and Government in pursuing policies which are harmful to clients health leading to closures of some hospitals, fewer community care services and thereby causing of long waiting lists, Allsop, et al, (1994) who examined formal complaining in the National Health Service (NHS) in Britain reported that the health professionals’ integrity sometimes came under attack. For example doctors, nurses and health service agents were blamed for services failure; nurses were accused of failing to monitor patient conditions and not attending to their basic needs. Doctors were accused of failure to provide information, offer emotional support and being self-centered, (Coyle 1999).

Similarly, MND a mental health charity organization that studied 343 service users in the past five years in England and Wales reported that 75% of the users criticized the staff for being remote and unavailable. The same percentage claimed that being in hospital made them “worse than better”. A patient stated “some staff were indifferent in a frightening way : - cold, distant and even threatening, a few nurses were sarcastic and bullying” (MIND, 2000). These patients reported that the nurses’ attitude did little to protect patients’ privacy and dignity.

Measuring client dissatisfaction seems to have been able to highlight clients various problems with the healthcare providers and healthcare services. The implications of this to nursing as a profession need to be taken seriously. Besides the effect of the outcome of care there is also a multiplying effect in which one person’s encounter can affect the attitude and opinion of many. Potter and Perry (1993) warned that an unhappy client might inform the immediate family, extended family, neighbours, friends, and co-workers. So nurses should note those seemingly simple acts such as, a cold food tray, failure to respond to a call, late treatments, unemptied bedpan, delayed pain medication can result in client dissatisfaction. (Potter and Perry 1993).

Nurse’s goal of achieving client satisfaction can only be attained when there is a commitment to putting client first and attending to him/her. Client’s dissatisfaction should not be tolerated as even percentages as low as 5% can be the disastrous (Pop. Report, 1998).

Summary of Literature Review

The literature reviewed for this study covered many relevant areas such as the concept of satisfaction, the consumers and Patients’ Bill of Right, the healthcare system and services, caring, client’s perception of caring, clients’ expectations, satisfaction and dissatisfaction with care, among other issues.

Satisfaction in this study was defined as a sense of commitment emanating from perceived needs met. This definition highlighted the need for care providers to adequately identify clients’ needs so that they can be able to meet them. Williams, (1997) pointed out that a relationship must be built with the client in order to provide individualized care to ensure clients satisfaction. Literature reviewed also revealed that satisfaction sometimes depend on the client’s locus of control (Latham, 1996).

The locus of control could be internal or external. For patients with internal locus of control, personal characteristics, such as self-esteem was found to affect their satisfaction with care. While for clients with external locus of control, factors such as fulfilling clients’ information and education needs (Auerbach 1980, Ley 1993, Lathen 1993), caregivers’ caring actions (Larson and Ferketich 1993) and increased clients’ perception of empowerment in the caregiver-client relationship (Roberts, Krouse and Michaud 1995) were found to affect satisfaction. Other factors found to affect clients’ satisfaction with care is the state of healthcare delivery system with its structures and processes (Starfield 1997).

The healthcare delivery system as it is today was said to have undergone several changes since the 1970s and 1980s. The changes were driven by some socio-economic and demographic factors. The social factors related to healthcare consumers or clients demand for participation in decision-making processes bothering on their health.

This has led to a shift in orientation and focus from disease to health and wellness programmes (Yoderwise 1999). It also led to changes in status of healthcare clients from passive patients in a paternalistic relationship with healthcare providers to well informed healthcare consumers or clients with power and choices in a partnership relationship with the healthcare providers (Yoderwise 1999, Melville 1999).

Likewise, the economic factors was occasioned by the global inflation of the 1970s and 80s (Starfield 1997; Stanhorp and Lancaster 1997). This resulted in the cost of healthcare services. In many developing countries like Nigeria, this problem coupled with problems of mismanagement, misappropriation and corruption resulted in the crippling of healthcare delivery systems in these countries (Madubuike 1996).

The resultant effects were dilapidated hospitals and other healthcare structures, reduced number of healthcare providers (brain-drain syndrome), and shortage of drugs (Soyibo 1999). All thses seemed to have threatened the quality of healthcare services and expectedly client’s satisfaction with care.

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In the U.S., the threat to quality of healthcare in spite of high cost of services resulted in very serious consumers’ protests. The U.S. government responded by adopting several measures like the institution of the managed care organizations that were given incentives to provide care at lowered cost without jeopardizing the quality of care (Perry and Potter 2001).

Also in a bid to ensure that clients’ needs and agitations were taken care of, the American Hospital Association formulated the Patients Bill of Rights. It was intended to empower the clients and also provide a working policy for the healthcare professionals to ensure that clients’ expectations are taken care of to ensure their satisfaction.

The results of most studies in the reviewed literature suggested that clients were generally satisfied with care received (Staniszewska and Ahmed 1999). However, most other researchers are contending these results. Aharomy and Strasser (1993) questioned the validity and reliability of the instrument used in data gathering for the studies. It was pointed out that the lack of an acceptable definition of the concept of satisfaction and the absence of conceptual framework to describe it posed a valid problem.

In the light of that, alternative study to clients’ satisfaction studies have been suggested, as it was observed that for reasons such as culture, etiquette, and politeness, some clients respond positively to the word satisfaction without actually meaning it (Pop. Report, 1997). This in event makes the actual measurement of the satisfaction with healthcare received difficult. As a fall out of this, Coyle (1999) rather suggested that a measurement of clients’ dissatisfaction with care, which he found gave more objective results. In some dissatisfaction studies, healthcare professionals were indicted for insensitivity.

Conceptual Framework

Client satisfaction with care is one of the most important goals of the health care delivery system. It is an outcome of the quality of care delivered.

The client enters into an encounter with the providers of healthcare with an expectation of having his/her needs met. Equity demands that the client having fulfilled his part of seeking his choice caregiver and paying for the services should receive satisfaction care.

Client satisfaction has been found not to depend only on technical provision of care but the way it is provided (Pop Report, 1999). This study is guided by a theoretical framework-taking cognizance of these factors. The relevant theories are Malow’s theory of human needs the expectancy theory and the equity theory.

Abraham Maslow’s Hierarchy of Human Needs:

Satisfaction can be discussed using the Maslow’s theory of basic human needs. Each client enters the healthcare delivery service with a need. The need could be physiological, social or spiritual. The caregiver at first encounter with the client assesses the clients’ needs. An accurate diagnosis of the need of highest priority and its successful resolution sets the pace for client satisfaction with care.

Abraham Maslow deriving principally from his professional clinical experience sought to explain why people were driven by particular times. He found that human needs are arranged in a hierarchy, from the most pressing to the least pressing. Maslow postulated that a need becomes a motive when it is aroused to a sufficient level of intensity. According to Kotler and Armstrong (1997).

A motive or drive is a need that is sufficiently pressing to direct the person to seek satisfaction. Maslow’s theory comprises of three main premises. The first is that all humans at any given time have specific needs that are not fully satisfied. These unsatisfied needs result in a state of tension or discontentment, if he is successful in overcoming one need, another unsatisfied need will immediately take its place.

Secondly, a satisfied need no longer serves as a motivation, only unfulfilled needs have ability to provoke human action. Thirdly human needs are ordered sequentially in a hierarchy, from lower to higher level needs. Higher level needs emerged only when those immediately preceding them have been satisfied in a process known as satisfaction progression. In order of importance, the needs are:

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Abraham Maslow described the pyramid in 1955. he sought to explain why people were driven by particular needs at particular times. Maslow’s pyramid of human needs showed that a person’s needs are in a hierarchy moving from fulfillment of basic needs to higher levels of needs with the ultimate goal of integrated human function and health.

One of the clinicians/ healthcare workers’ important functions in healthcare delivery is to identify the patient’s immediate needs and take measures to alleviate them so that the patient will be satisfied and move on to another level. Inability to do this, results in client dissatisfaction and frustration, (John 1997). Maddi (1989) citing Maslow (1955) identified some traits of fulfilled or satisfied people as:

Maddi (1989).

The above relate to the internal factors that characterize satisfaction as identified by Latham (1996). There was the suggestion that an internally satisfied client is more likely to be easily satisfied with caregivers caring acts than one who is not. This relates to the locus of control and would more readily act to change unacceptable situation in the healthcare delivery service than the client with an external locus of control (Kassim 1998).

In relation to this study the theory was used to identify clients’ needs. Data collected was in tandem with this theory. For example, questions eliciting information on clients’ satisfaction with physiological needs met included items on provision of useful/helpful equipment by the Community Assessment and Rehabilitation Team (CART) members to facilitate achievement of comfort.

Clients’ satisfaction with the provision of their information and education needs were captured by questions on whether clients were informed about how to contact the CART members when needed and also whether the CART members were listening to client’s needs.

The fact that clients satisfaction with whether they were asked by the caregivers (CART members) regarding what they hope to achieve by seeking care represents finding information about client’s achievement of self-actualisation viz: getting well as fully as possible. Also whether client’s were accorded some respect and treated politely elicited clients’ satisfaction with the CART members meeting their aesthetic needs.

Expectancy Theory

This is a motivational theory that sought to explain people’s behaviour, Vroom (1964) proposed that people are rational, intelligent and capable of pursuing actions based on their beliefs and expectations. They analyze the benefits and the costs of their possible courses of action.

Yoderwise (1999) stated that an expectancy process is composed of three components namely effort, instrumentation and valency.

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Effort

This component refers to the individual’s assessment of a situation. The likelihood that a certain effort is worthwhile and will be rewarded is considered. The individual measures his ability to pursue a certain goal and his chances of success. The reward of a positive outcome motivates the individual further.

Clients’ choices of care facilities and the efforts made to seek caregivers are based on their belief that the caregivers will meet their expectations. The clients’ attitude and behaviour towards care givers and healthcare services are shaped by the degree to which they facilitate the attainment of valued outcome. The valued outcome for health services clients are, improved health status and satisfaction with the process of caring.

Instrumentation

This refers to the actual performance of the activities to produce the desired outcome (Yoderwise, 1999).

Clients expect caregivers not only to care for them by performing their skills but also to involve them. Clients expect to participate in their caring activities. They expect caregivers to give them relevant information to facilitate their decision-making. They expect to be consulted in decisions concerning their care. They expect to be taught how to take care of themselves, and be adequately prepared for discharge.

Assisting the clients helps them to fulfill the instrumentation process and results in the positive outcome of client satisfaction. In the performance of their caring activities caregivers are also involved in the instrumentation process. The performance of the activities according to the client’s expectations leads to an outcome of client satisfaction.

Valency

One of the characteristics of expectation is the value placed on the outcome of the encounter. This attribute is referred to as the valency of the effort-performance expectancy process. The value attached to an expectation determines the level of satisfaction or dissatisfaction with the outcome.

Stanizewska and Ahmed (1999) found that clients differentiate between aspects of care they value and those they do not value. In view of that, an initial and episodical assessment of client’s expectation of care is necessary to determine valued aspects of care.

The client’s satisfaction is based on caregiver’s performance. The absence of basic equipment for care like thermometers and lack of basic amenities like running water, safe bedside lockers, clean beddings are below clients expectations, and are likely to lead to client’s non-satisfaction.

Clients value their relationship with family and friends and expect caregivers to provide their medication on time, give them information adequately and in the language they understand.

Caregivers’ inability to perform as expected results in dissatisfaction with care while performance results in satisfaction with care.

Equity Theory

This is another theory postulated to explain people’s expectations and behaviour. Kassim (1997) stated that the equity theory is based on peoples’ expectation that the ratio of input should be comparable to the output.

It was also found that individuals lower their expectations and performances in order to restore equity if initial expectations are not met (Kassim 1997).

The consumer’s awareness campaign for improved quality of care was based on the equity theory. The escalating cost of healthcare services demanded a commensurate increase in quality of care. The observed absence of these led to consumers’ agitation. The passing of the consumers’ Bill of Rights and Patients’ Bill of Rights are efforts in the USA to restore equity.

In this study, the healthcare providers’ caring actions, coupled with the facilities and their activities constitute the inputs. The output is the outcome of care. The theory of equity postulates that the ratio will be equitable, that is there will be balance.

The client as the recipient of care will evaluate the caring action as they meet his expectations and this determines his satisfaction with the performance. Clients’ satisfaction with care or the expected outcome will reveal the adequacy of the input. Non-satisfactory outcome suggests inadequate inputs.

This theory can also be used to understand client’s low expectations in countries where quality of healthcare is generally low. Gropenzano (1993) found that individuals who felt unhappy about their perception of a situation tried to relieve their unhappy state by restoring equity. They do so by either giving up their earlier position and try to convince themselves that equity was already there, or they work less to balance the input and output, or they protest the situation.

In this study attempts were made to determine the balance between input (infrastructure and caregivers caring activities) and output-clients satisfaction.

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