INTRODUCTION

In the competitive health care arena of today, patients’ satisfaction with health care they received becomes a priority issue. Satisfied patients are more likely to seek and comply with prescribed treatment regimes (Taylor & Benger 2004). Patients who seek emergency care form a diverse group as they have a wide spectrum of health care needs; some people seek care for episodic, acute problems, while others seek care for acute exacerbations of chronic illnesses (Elisabeth 2004; Bruce et al. 1998). The health care provider in the ED is responsible for meeting the various needs of these patients. Treatment plans varies according to the acuteness and problems presented by the patients. Health care providers in the ED need to have an adequate blend of medical and nursing knowledge (Davis & Bush 2003). Adequate medical knowledge is required to identify the correct diagnosis and to prescribe appropriate medical intervention. Educating patients about their condition and treat-ment, addressing effective means of self care and adaptation to change in lifestyle, and if necessary, discussing ways to prevent recurrence of sickness are integral parts of the plan of care.

A hospital ED is recognized as the front door where a significant number of in-patient admission take place. According to Gertdz & Bucknall (2001), all patient visits to an ED should begin with triage. In ED, the health provider plays an important role as a gatekeeper toward delivery of care and patient satisfaction (Raper et al. 1999). The tremendous increase in the number of patients visiting ED has contributed to patient dissatisfaction. Satisfaction with the health providers is a predictor of overall patient satisfaction (Elder et al. 2004).  Although definitions of patient satisfaction differ slightly from each other, there is general consensus among researchers that patient expectation; demographic charac-teristic and nature of illness are important factors, which contribute to the total level of patient satisfaction (Han et al. 2003). 

All patients presented to ED HUKM will undergo a two-tier triage process com-prising of primary triage and secondary triage. The 5-level triage category system adopted and practiced is similar to that used in United Kingdom and Australia. A conceptual framework of the ED HUKM is shown in Figure 1. Patients are divided into 5-level triage categories, triage 1 where immediate resuscitation and five beds are available in the resuscitation bays. Emer-gency cases are triaged as triage 2A and 2B. Intervention will be provided in triage 2A less than 10 minutes and six beds are catered to meet patients’ needs, however, for triage 2B cases treatment is within 30 minutes and there are five beds. Urgent cases are categorized as triage 3. Treat-ments will be rendered not later than 60 minutes. It consisted of five cubicles with five beds and one Plaster of Paris (POP) room available for the patients at ED. Non-urgent cases such as minor conditions or old injuries, awaiting diagnostic tests and cases to be reviewed are placed at triage 4. Patients will be seen by doctor within two hours. Patients are reminded to call health care providers if the need arises, for example, when they feel intolerable pain or have sudden deterioration of conditions which may be life threatening.

The aim of the study was to identify factors that influence patient satisfaction with the ED HUKM. From some researcher’s personal encounters using observation and interview they have discovered numerous grievances and dissatisfaction expressed by the patients and relatives who have seek services in the ED HUKM.  It is hoped that the findings will be able to assist health providers in defining their roles and ultimately to improve the quality of care delivered to emergency patients. 

MATERIALS AND METHODS

This study was undertaken at ED HUKM from January 2007 till March 2007. A convenient sample was drawn from the population of patients attending the ED HUKM over a period of three months. Patients were included  if they were at least 18 years of age, able to communicate with the interviewers in Malay or English language and assigned as category triage 3 or triage 4 (HUKM guidelines). Category triage 3 patients are semi-urgent patients who must be seen in the ED and should be re-evaluated during the waiting period. Triage 4 patients are non-urgent patients who may safely wait for a long period to be seen or may be triaged for care to a clinic or follow up. Exclusion criteria were: patients who were in police custody or under protective custody, had history of mental illness, abortion or sexual assault and direct admission to resuscitation room. 

Patients’ satisfaction was measured using the Consumer Emergency Care Satisfaction Scale (CECSS) which was developed by Davis in 1988 and revised in 1997 to examine patient satisfaction to triage nursing care (Davis et al. 2003). Questions were translated by our resident Consultant Anaesthetist at ED HUKM to cater for Malaysian patients’ needs. The CECSS consists of 19 items scored on a 5 point Likert type scale ranging from completely agree to completely disagree. Two subscales comprise the CECSS which is caring (12 items) and teaching (3 items). Four items are negatively worded to minimize response set and are not scored. Each item asks for information about patients’ satisfaction with ED nursing care.

The scoring method established by Davis et al. (2003) had the total possible score ranging from 15 to 75 in which the four negatively worded filter items do not contribute to the total score. A total score of >45 indicates patient satisfaction and scores <44 indicated dissatisfaction. Scores on the caring ranged from 12 to 60 with scores >36 indicating satisfaction and scores on the teaching components ranged from 3 to 15 and a score of >9 indicates satisfaction. Demographic data of the patients include patients’ age, gender, race, educational level, marital status, employment sector, monthly income, and reasons to seek treatment at ED HUKM.

RESULTS

The majority of participants who reported satisfaction comprised 75 respondents (75%) whereas 25 respondents (25%) were dissatisfied with the triage system used at the ED HUKM. Demographic data such as gender, race, age, educational level, employment sector, monthly income and reasons to seek treatment at ED HUKM are illustrated in Table 1. The results for the CECSS total and subscales are summarized in Table 2, with higher scores indicated greater satisfaction. The t-test was used to examine differences between males and females in terms of patient satisfaction. There were no significant difference (t=0.308, p values >0.05) found between male and female patients with total CESCC scores. A Pearson product moment correlation coefficients was used to examine the relationship between total and subscale patient satisfaction. The results showed positive relationship between total and subscale patient satisfaction scores, caring scores (r=0.905, p value <0.05) and teaching scores (r=0.695, p vales < 0.05).

From this study the five items with the highest score ranking were: “the nurse/medical assistant explained things in terms I could understand”; “the nurse/ medical assistant gave me instructions about caring for myself at home”; “the nurse/medical assistant seemed genuinely concerned about my pain, fear and anxiety”; “the nurse/medical assistant was skilful in performing his/her duties and the nurse/medical assistant seemed to understand how I felt”. Items with lowest scores were as follow: “the nurse/medical assistant treated me as a number instead of as a person”; “the nurse/medical assistant should be more attentive than he/she was”; “the nurse/medical assistant seemed too busy at the nurses’ station to spend time talking with me”; “the nurse/medical assistant understood when listening to my problem and the nurse/medical assistant gave me a chance to ask questions”.

DISCUSSION

The majority of patients were satisfied with caring and teaching aspects rendered by the health providers at ED HUKM. The results have shown that patients had been given clear explanations and adequate details about their treatment.  Health care providers played important roles by providing health teaching and advice to their patients whilst they seek treatment at ED HUKM. Satisfied patients are more likely to comply with prescribed treatments and therefore may have better outcome, which bring benefits to both patients and health care providers (Taylor & Benger 2004; Elder et al. 2004). Satisfied patients are more likely to return for follow up treatment. The results indicated that 52% of the patient visit to ED HUKM were referral and followed up cases.

Patient satisfaction is not a uniform term as its definition varies. Amongst patients and health care provider researchers, understanding of satisfaction differs. Patient satisfaction can be conceptualized as the degree of congruency between a patient’s expectation of care and the actual care received (Elaine et al. 2004; Debenke & Decker 2002).  Although definitions of patient satisfaction differ slightly from each other, there is general consensus among researchers that patient expectation; demographic characteristic and patients’ characteristic are important factors which contribute to the total level of patient satisfaction (Han et al. 2003; Grief 2003). Unlike in this study, the demographic data showed no significant differences with the total scores of patient satisfaction, hence further research need to be done to identify patients’ characteristic factor.

Patients who participated in this study were generally satisfied with the areas covered. The correlations were statistically significant; higher patient satisfaction scores were associated with higher caring and teaching as their contributing factors of the health care provided at ED HUKM. Consequently, there is a growing need for patient education in the delivery of care in order to achieve better health, reduce cost, less complication and revisit to hospital (Faten 2005; Elisabeth 2004). Teaching also assists patient to develop their self care abilities through an increase in knowledge, a more positive attitude and improved skills that enable them to maximize their functioning and quality of life (Davis et al. 2003; Ifantopoulos et al.  1999). According to Elaine et al. (2004),  though it is difficult for health care providers to implement health teaching in such an acute setting, providing simple explanation about their illness could allay fear and anxiety.

From this study, CECSS questionnaires with regard to the negative items for example: “the nurse/medical assistant treated me as a number instead of as a person”; “the nurse/medical assistant should be more attentive than he/she was” and finally the “nurse/medical assistant seemed to be busy at the nurses’ station to spend time talking with me” were among the lowest five scored. This could imply that the attention given by the health care providers was adequate and they were attentive to patients’ needs whilst at ED HUKM. Besides that, the result indicated that patients were satisfied with the amount of time spent with them and the good communication skill. Moreover, the patients considered that the health care providers were sensitive by not labelling them as numbers rather than individuals. By ranking the negative aspect of the health care providers has shown that patient’s impression towards health care providers at ED HUKM were warm and receptive towards their needs. Teaching and caring behaviours of health care providers need to be high-lighted at the ED HUKM.

CONCLUSION

We conclude that patients seeking treatment at ED HUKM are satisfied with the delivery of care, health-teaching and caring provided by the health care providers. It is important to know which areas of care in the ED need to be adopted to meet the patient’s expectations. Health care providers must encourage the evaluation of patient satisfaction and the fulfilment of patient’s expectations. Patients’ satisfaction will remain an important quality outcomes measure of emergency care in a hospital.