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Satisfaction of intensive care unit patients linked to clinical and organisational factors: A cross-sectional multicentre study

Open AccessPublished:November 28, 2022DOI:https://doi.org/10.1016/j.aucc.2022.10.013

      Abstract

      Background

      The satisfaction of critical care patients with the nursing care they receive is a key indicator of the quality of hospital care.

      Objectives

      The objectives of this study were to analyse the level of satisfaction of critical care patients in relation to the nursing care received and to determine the relationship between the level of satisfaction and sociodemographic, clinical, and organisational variables.

      Design

      This was a prospective, descriptive correlational study.

      Setting and methods

      The population consisted of all patients discharged from the intensive care units (ICUs) of 19 hospitals in Spain between December 2018 and December 2019. The level of satisfaction was measured using the validated Nursing Intensive Care Satisfaction Scale, and sociodemographic, clinical, and organisational data were collected.

      Results

      Participants' mean age (n = 677) was 59.7 (standard deviation: 16.1), and 62.8% of them were men (n = 426). Satisfaction with the nursing care received was 5.66 (SD: 0.68) out of a possible 6. The score for overall satisfaction presented statistically significant relationships with the hours of mechanical ventilation (p = 0.034), with the participant's perception of own health status (p = 0.01), with the participant's perceived degree of own recovery (p = 0.01), with the hospital's complexity level (p = 0.002), with the type of hospital (p = 0.005), and with the type of ICU (p = 0.004). Finally, the logistic regression model shows that the Nursing Intensive Care Satisfaction Scale score was not linked to age or sex but did have a statistically significant relationship with the perceived degree of recovery (p < 0.001) and the type of ICU (p=<0.001). The variables that predicted satisfaction were age, degree of recovery, and the type of ICU.

      Conclusion

      Several studies show that patient satisfaction is related to the patient's perceived health status and perceived degree of recovery, a finding that is confirmed in our study. Our study moves beyond these outcomes to show that the hours of mechanical ventilation and the characteristics of the hospital also have a significant relationship with patients' satisfaction.

      Keywords

      1. Introduction

      Patient satisfaction is a complex and multidimensional concept.
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      1.1 Background

      The needs of the critical patient are not only biological or physical but also linked to their experiences, values, beliefs, and culture.
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      La percepción del paciente crítico sobre los cuidados enfermeros: una aproximación al concepto de satisfacción [Perception of the critical patient on nursing cares: an approach to the concept of satisfaction].
      To provide quality care, nurses need to acquire competencies related to interpersonal skills and attitudes (including verbal and nonverbal communication) and the relationship with the patient, the family, and other professionals. Doing so from a perspective of empathy makes it possible to treat the person within the person's own subjective experience.
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      Questionnaires are the most commonly used instruments for measuring the quality of nursing care or satisfaction with nursing care, and patient opinions are the best source of information.
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      Validated scales include The Risser Patient Satisfaction Scale (RPSS),
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      the Caring Assessment Instrument (CARE-Q),
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      The Monica–Oberst Patient Satisfaction Scale (LOPPS),
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      the Service Quality (SERVQUAL),
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      the Critical Care Patient Satisfaction Survey,
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      the Newcastle Satisfaction with Nursing Scale (NSNS),
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      the Consumer Emergency Care Satisfaction Scale (CECSS),
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      the Patient Satisfaction with Nursing Care Quality Questionnaire (PSNCQQ),
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      the Patient's Assessment of Quality Scale-Acute Care Version (PAQS-ACV),
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      Understanding and measuring patients' assessment of the quality of nursing care.
      and the Nursing Intensive Care Satisfaction Scale (NICSS).
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      • et al.
      Nursing intensive-care satisfaction scale [NICSS]: development and validation of a patient-centred instrument.
      ,
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      • de la Cueva-Ariza L.
      • Cuzco C.
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      • et al.
      Psychometric properties of the nursing intensive care satisfaction scale: a multicenter cross-sectional study.
      However, only the NICSS incorporates the critically ill patient's perspective both in terms of design (content) and validation.
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      • et al.
      Nursing intensive-care satisfaction scale [NICSS]: development and validation of a patient-centred instrument.
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      • Martínez-Momblan M.A.
      • de la Cueva-Ariza L.
      • Cuzco C.
      • Alonso S.
      • et al.
      Psychometric properties of the nursing intensive care satisfaction scale: a multicenter cross-sectional study.
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      • Trujols-Albet J.
      Towards increased incorporation of the patient perspective in the design of evaluation tools for the evaluation of efficiency and quality of patient care.
      Numerous researchers
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      Patient satisfaction with the quality of nursing care.
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      • Hasna F.S.
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      have explored the relationship between patient satisfaction and sociodemographic and clinical variables, such as age, sex, level of education, employment status, length of ICU stay, and perception of health status. However, most of the published studies have been carried out in a single centre and few have explored the factors related to ICU organisation. Two systematic reviews report that the effect of sociodemographic and clinical factors is equivocal except for the positive association between age and satisfaction level.
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      • Amenta P.
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      ,
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      • Kimber A.
      • Storey L.
      • et al.
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      2. The study

      2.1 Aims

      The aim of this study was to explore satisfaction among ICU patients with the nursing care received and the potential relationship between satisfaction and sociodemographic, clinical, and organisational variables.

      2.2 Design

      This was a multicentre, prospective, descriptive correlational study that forms part of a larger investigation in which we first analysed the psychometric properties of the NICSS.

      2.3 Participants

      Nineteen hospitals in Spain participated in the study: 15 public hospitals—5 secondary level and 10 tertiary level—and four private hospitals—three secondary level and one tertiary level—according to the World Health Organization (WHO) definition.
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      • Adam T.
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      • Evans D.B.
      • et al.
      Making choices in health: WHO guide to cost-effectiveness analysis.
      The nurse-to-patient ratio was 1:2, except in two of the hospitals (10.5%), where it was 1:1.
      Nonprobabilistic and consecutive sampling was employed. Inclusion criteria were patients (i) oriented to person, place, and time and (ii) able to read and write. Exclusion criterion was patients (i) discharged to another hospital or directly to home.

      2.4 Data collection

      Once the patient had been discharged from the ICU and within a period not exceeding 48 h, the principal investigator of each participating ICU visited the patient's hospital room to explain the purpose of the study and invite the patient to participate. After receiving the patient's agreement to participate, the patient signed the informed consent form. The collaborating researcher then left the instruments with the patient and returned to collect them 24 h later. The researchers who delivered the questionnaire had no direct relationship with the patient.
      Two self-administered instruments were used for data collection. The first instrument contained 13 questions about sociodemographic information (age, sex, marital status, and education level), clinical data (length of ICU stay, hours spent on mechanical ventilation, perceived health status from 1: terrible to 10: excellent, perceived degree of recovery from 1: “I haven't improved at all” to 10: “I've fully recovered”), and organisational data (complexity level, hospital, ICU type, type of patient cubicle).
      The second instrument was the NICSS, which evaluates the satisfaction of critical care patients with the nursing care received during their ICU stay.
      • Romero-García M.
      • de la Cueva-Ariza L.
      • Benito-Aracil L.
      • Lluch-Canut T.
      • Trujols-Albet J.
      • Martínez-Momblan M.A.
      • et al.
      Nursing intensive-care satisfaction scale [NICSS]: development and validation of a patient-centred instrument.
      The NICSS is a self-reported 49-item scale comprising four factors: F1 Holistic Care (physical and emotional aspects), F2 Communication Modes (verbal and nonverbal), F3 Professional Behaviours, and F4 Consequences (the patient's experiences and feelings related to the nursing care received). The first three factors, which offer descriptions of the nurse's care actions, have a total of 37 items (F1: 20, F2:6, F3:11). The fourth factor has 12 items. Responses are on a six-point Likert scale (1 = strongly disagree to 6 = strongly agree). In Factor 4, there are three items (44, 48, and 49) formulated positively but expressing an unfavourable opinion; therefore, the scoring is reversed. NICSS scores are obtained by averaging applicable items. The ranges of clinical significance for the NICSS scores are 1–3.5 (dissatisfied) and >3.5–6 (satisfied).
      As shown in previous phases of the study (Romero-Garcia et al., 2018)
      • Romero-García M.
      • de la Cueva-Ariza L.
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      • Lluch-Canut T.
      • Trujols-Albet J.
      • Martínez-Momblan M.A.
      • et al.
      Nursing intensive-care satisfaction scale [NICSS]: development and validation of a patient-centred instrument.
      , the NICSS has high reliability, with values above 0.95. The intraclass correlation coefficient for the total scale was 0.83, indicating good temporal stability. Construct validity showed good fit and four-factor structure, according to the theoretical model. The validity of the criterion showed a correlation between moderate and high (range: 0.46 to 0.57).
      • Romero-García M.
      • de la Cueva-Ariza L.
      • Benito-Aracil L.
      • Lluch-Canut T.
      • Trujols-Albet J.
      • Martínez-Momblan M.A.
      • et al.
      Nursing intensive-care satisfaction scale [NICSS]: development and validation of a patient-centred instrument.
      ,
      • Romero-García M.
      • Alcalà-Jimenez I.
      • Martínez-Momblan M.A.
      • de la Cueva-Ariza L.
      • Cuzco C.
      • Alonso S.
      • et al.
      Psychometric properties of the nursing intensive care satisfaction scale: a multicenter cross-sectional study.

      2.5 Ethical considerations

      The study was authorised by the management of the participating centres and the Clinical Research Ethics Committee (nº2018/7818/l) of the lead hospital and by the ethics committees of the other hospitals, in accordance with Eisner's recommendations (1998). Participants' confidentiality was maintained. Each participant was assigned an alphanumeric code. Participation was voluntary, and subjects could withdraw at any time.

      2.6 Data analysis

      Batbaatar et al.
      • Batbaatar E.
      • Dorjdagva J.
      • Luvsannyam A.
      • Savino M.
      • Amenta P.
      Determinants of patient satisfaction: a systematic review.
      show that the percentage of satisfied people is higher than 80%, so this proportion was used as a reference to calculate the sample size. A sample of 665 individuals was sufficient to estimate, with a confidence of 95% and a precision of 0.034 percentage units, a population percentage that is expected to be around 80%. We expected a dropout rate of 20%.
      Frequencies, percentages, and measures of central tendency and dispersion were obtained. We calculated satisfaction levels overall and by factor. The descriptive values of each of the items that make up the scale were calculated, distributed by factors, and categorised into two categories: dissatisfied and satisfied.
      To analyse the relationship between patient satisfaction and sociodemographic, clinical, and organisational variables, we conducted a bivariate analysis. We compared the overall mean score and the score for each factor according to age, sex, marital status, education level, length of stay, hours of invasive mechanical ventilation, perceived health status, and perceived degree of recovery. We used the nonparametric Wilcoxon–Mann–Whitney test to compare two independent groups and the nonparametric Kruskal–Wallis test to compare more than two independent groups. Finally, to examine the relationship between the mean score of the NICSS and the perception of the degree of recovery and the perception of health status, the Spearman correlation test was used. Multivariate linear regression analysis was carried out to examine satisfaction with nursing care. The logistic regression model was based on previously published research and included the variables age, sex, perceived degree of recovery, and the type of ICU.
      • Akhtari-Zavare M.
      • Abdullah M.H.
      • Syed Hassan S.T.
      • Binti Said S.
      • Kamali M.
      Patient satisfaction: evaluating nursing care for patients hospitalized with cancer in Tehran Teaching Hospitals, Iran.
      ,
      • Romero-García M.
      • Delgado-Hito P.
      • de la Cueva-Ariza L.
      • Martínez-Momblan M.A.
      • Lluch-Canut M.T.
      • Trujols-Albet J.
      • et al.
      Level of satisfaction of critical care patients regarding the nursing care received: correlation with sociodemographic and clinical variables.
      All tests of significance were two-tailed, and statistical significance was defined as p < 0.05, unless otherwise stated. The data processing and analysis was performed with the statistics package R version 3.1.2 for Windows.

      3. Results

      The average age of participants (n = 677) was 59.7 years (standard deviation: 16.1 years), and 62.8% of them (n = 426) were men. Table 1 shows selected sociodemographic and clinical characteristics of the study participants (See Fig. 1).
      Table 1Demographic and clinical characteristics (n = 677).
      n (%)
      Age,

      mean (SD)
      59.7 (15.7)
      SexMale426 (62.9%)
      Marital statusMarried404 (59.7%)
      Cohabiting49 (7.2%)
      Single101 (14.9%)
      Separated22 (3.3%)
      Divorced40 (5.9%)
      Widowed61 (9%)
      Level of educationNone91 (13.4%)
      Primary education239 (35.3%)
      Secondary education252 (37.2%)
      University95 (14%)
      Length of ICU stay (days),

      median [Q1; Q3]
      4.0 (2.0–7.0)
      Hours of invasive mechanical ventilation,

      median [Q1; Q3]
      9.0 [0.0; 48.0]
      Perceived health status (1–10),

      median [Q1; Q3]
      7.0 [5.0; 8.0]
      Perceived degree of recovery (1–10),

      median [Q1; Q3]
      8.0 [7.0; 9.0]
      Level of complexitySecondary level

      Tertiary level
      346 (51.1%)

      331 (48.9%)
      Type of hospitalPublic569 (84.0%)
      Private108 (16.0%)
      Type of ICUPolyvalent564 (83.3%)
      Specialised113 (16.7%)
      Type of patient cubicleOpen153 (22.6%)
      Closed, single occupancy487 (71.9%)
      Closed, double occupancy37 (5.5%)
      ICU, intensive care unit; SD, standard deviation.

      3.1 Satisfaction levels

      The mean score of the NICSS items was 5.66 (SD: 0.68) out of 6. Table 2 presents the results of the satisfaction levels obtained in each of the NICSS items, grouped into two categories: dissatisfied and satisfied.
      Table 2Satisfaction in each NICSS item, according to response category (dissatisfied or satisfied).
      Content of the summarised itemsDissatisfied n (%)Satisfied n (%)Mean (SD)
      F1. Holistic Care5.68 (0.65)
      Item 6. Ensured that I was not in pain4 (0.60%)673 (99.40%)5.78 (0.53)
      Item 7. Gave my medication on time3 (0.45%)674 (99.55%)5.79 (0.51)
      Item 8. Listened8 (1.19%)669 (98,81%)5.71 (0.63)
      Item 12. Gave continued care3 (0.45%)674 (99.55%)5.77 (0.52)
      Item 14. Paid attention to me43 (6.36%)634 (93.64%)5.64 (0.68)
      Item 15. Made sure that I was kept clean27 (3.99%)650 (96.01%)5.74 (0.59)
      Item 16. Respected my sleep and rest42 (6.21%)635 (93.79%)5.34 (1.04)
      Item 17. Treated my injuries well6 (0.89%)671 (99.11%)5.72 (0.60)
      Item 18. Moved me when I need it8 (1.19%)669 (98.81%)5.68 (0.64)
      Item 19. Were concerned for my comfort22 (3.25%)655 (96.75%)5.73 (0.58)
      Item 21. Maintained a relationship of trust37 (5.47%)640 (94.53%)5.66 (0.63)
      Item 22. Were attentive to my needs6 (0.89%)671 (99.11%)5.71 (0.59)
      Item 23. Showed patience while giving care8 (1.19%)669 (98.81%)5.71 (0.64)
      Item 24. Knew how to put themselves in my shoes15 (2.22%)662 (97.78%)5.55 (0.74)
      Item 27. Provided emotional support38 (5.61%)639 (94.39%)5.62 (0.71)
      Item 29. Were sensitive to my suffering7 (1.03%)670 (98.97%)5.61 (0.69)
      Item 32. Looked after me kindly6 (0.89%)671 (99.11%)5.73 (0.60)
      Item 34. Saw to my needs with tact/sensitivity22 (3.25%)655 (96.75%)5.72 (0.58)
      Item 36. Maintained close contact6 (0.89%)671 (99.11%)5.71 (0.60)
      Item 37. Took care of me in a personal way9 (1.33%)668 (98.67%)5.64 (0.68)
      F2. Communication Modes5.68 (0.65)
      Item 1. Introduced themselves12 (1.78%)665 (98.22%)5.70 (0.67)
      Item 20. Explained what they were going to do12 (1.78%)665 (98.22%)5.65 (0.68)
      Item 25. Answered questions22 (3.25%)655 (96.75%)5.70 (0.58)
      Item 26. Worked with a smile8 (1.19%)669 (98.81%)5.68 (0.66)
      Item 30. Looked at me when they walked in10 (1.48%)667 (98.52%)5.68 (0.66)
      Item 33. Helped me communicate7 (1.03%)670 (98.97%)5.67 (0.65)
      F3. Professional Behaviours5.71 (0.60)
      Item 2. Assisted me quickly12 (1.78%)665 (98.22%)5.67 (0.68)
      Item 3. Demonstrated technical ability22 (3.25%)655 (96.75%)5.73 (0.56)
      Item 4. Knew what they had to do8 (1.19%)669 (98.81%)5.72 (0.58)
      Item 5. Had a professional attitude6 (0.89%)671 (99.11%)5.75 (0.56)
      Item 9. Knew what to do20 (2.96%)657 (97.04%)5.72 (0.54)
      Item 10. Worked in a team16 (2.36%)661 (97.64%)5.75 (0.53)
      Item 11. Solved problems5 (0.75%)672 (99.25%)5.72 (0.58)
      Item 13. Showed that they enjoyed their work7 (1.03%)670 (98.97%)5.72 (0.60)
      Item 28. Anticipated the care needed18 (2.66%)659 (97.34%)5.50 (0.79)
      Item 31. The treatment was personal15 (2.22%)662 (97.78%)5.77 (0.51)
      Item 35. The care helped me to recover16 (2.36%)661 (97.64%)5.74 (0.54)
      F4. Consequences5.59 (0.79)
      Item 38. Optimistic21 (3.11%)656 (96.89%)5.44 (0.84)
      Item 39. Calm21 (3.10%)656 (96.90%)5.53 (0.83)
      Item 40. They valued my opinion24 (3.55%)653 (96.45%)5.43 (0.87)
      Item 41. Good7 (1.03%)670 (98.97%)5.63 (0.66)
      Item 42. In the nurse's hands35 (5.16%)642 (94.84%)5.41 (1.07)
      Item 43. Cared for by efficient nurses8 (1.19%)669 (98.81%)5.72 (0.61)
      Item 44. Like a number, an object23 (3.39%)654 (96.61%)5.68 (0.78)
      Item 45. Grateful23 (3.39%)654 (96.61%)5.69 (0.67)
      Item 46. Physically secure18 (2.66%)659 (97.34%)5.57 (0.77)
      Item 47. With a desire to keep living13 (1.92%)664 (98.08%)5.67 (0.72)
      Item 48. Alone26 (3.85%)651 (96.15%)5.63 (0.79)
      Item 49. Unattended11 (1.63%)666 (98.37%)5.72 (0.67)
      Total NICSS5.66 (0.68)
      SD, standard deviation; NICSS, Nursing Intensive Care Satisfaction Scale.
      The ranges of clinical significance for the NICSS scores are 1–3.5 (dissatisfied) and >3.5–6 (satisfied).
      Overall scores for each factor were very high, although F4 Consequences had a slightly lower average. In F1 Holistic Care, the items with the highest proportion of satisfied participants were (6) ensured that I was not in pain, (7) gave my medication on time, (12) gave continued care, (32) looked after me in a kindly way, (19) were concerned for my comfort, and (15) made sure that I was kept clean. In relation to F2 Communication Modes, the items with the highest proportion of satisfied participants were for (1) introduced him/herself, (25) answered questions, (30) looked at me when they walked in, and (26) worked with a smile. From F3 Professional Behaviours, the items with the highest proportion of satisfied participants were (1) worked in a team, (31) the treatment was personal, (5) had a professional attitude, and (35) the care helped me recover. Finally, for F4 Consequences, the items with the highest proportions of satisfied patients were (42) cared for by efficient nurses, (45) grateful, (44) like a number, an object, and (47) with a desire to continue living. (As explained in the Data collection, item 44 is a negative opinion, so scoring is reversed; participants marking 1, 2, or 3 for this item were classified as satisfied).
      For all items, the proportion of patients who were satisfied was very high. However, for each factor, we can point out some items with a slightly lower proportion. Within F1 Holistic Care, the items with the lowest proportion of satisfied patients were the (24) knew how to put themselves in my shoes and (16) respected my sleep and rest. In relation to F2 Communication Modes, the items with the lowest proportion of satisfied patients were (20) explained what they were going to do and (33) helped me communicate. In F3 Professional Behaviours, the items with the lowest proportion of satisfied patients were (28) anticipated the care that I needed and (2) assisted me quickly. Finally, for the F4 Consequences, the items with the lowest proportion of satisfied patients were (42) in the nurse's hands, (40) they valued my opinion, and (38) optimistic.

      3.2 Relationship between the level of satisfaction and sociodemographic, clinical, and organisational variables

      Table 3 reports the relationship between sociodemographic, clinical, and organisational variables with the level of satisfaction. The variables that presented a statistically significant relationship with the level of satisfaction of the total NICSS were the hours of mechanical ventilation, perceived health status, perceived degree of recovery, hospital complexity level, hospital type, and ICU type. Concretely, patients who scored higher on the total NICSS were those who were subjected to fewer hours of mechanical ventilation, who had a higher perceived health status, who had a higher perceived degree of recovery, and who had been admitted to a secondary level private hospital and a polyvalent ICU. In addition to these correlations with the total NICSS score, perceived health status and perceived degree of recovery also had a statistically significant relationship with each of the factors considered separately (p < 0.01∗).
      Table 3Relationship between the level of overall satisfaction and sociodemographic, clinical, and organisational variables.
      Total NICSSNMedian [Q1; Q3]p-value
      SexMale426284 [265; 293]0.359
      Age18–50 years163281 [262; 291]0.553
      51–62 years173286 [262; 292]
      63–72 years168284 [272; 292]
      73–90 years173282 [269; 293]
      Marital statusMarried404284 [269; 292]0.146
      Cohabiting49282 [262; 291]
      Single101280 [260; 289]
      Separated22286 [278; 294]
      Divorced40283 [264; 293]
      Widowed61285 [272; 293]
      Level of educationNone91280 [265; 292]0.994
      Primary education239283 [268; 292]
      Secondary education252285 [262; 292]
      University95284 [271; 291]
      Level of complexityLevel II346285 [271; 293]0.002∗
      Level III331282 [262; 291
      Type of hospitalPublic569283 [265; 291]0.005∗
      Private108288 [273; 294]
      Type of ICUPolyvalent564284 [269; 293]0.004∗
      Specialised113281 [254; 289]
      Type of patient cubicleOpen153280 [263; 291]0.053
      Closed, single occupancy487285 [268; 293]
      Closed, double occupancy37285 [260; 293]
      rp
      Length of stay in ICU (days)6774 [2; 7]−0.050.240
      Hours of mechanical ventilation6779 [0; 48]−0.110.034∗
      Perceived health status (1–10)6777 [5; 8]0.16<0.01∗
      Perceived degree of recovery (1–10)6778 [7; 9]0.16<0.01∗
      NICSS, Nursing Intensive Care Satisfaction Scale.
      The NICSS has been used as a quantitative value that ranges between 49 and 294.
      ∗p < 0.05; r = Spearman.
      The logistic regression model shows that age, perceived degree of recovery, and the type of ICU had a statistically significant relationship to patient satisfaction for some factors and/or for the total NICSS score. For F1 Holistic Care, age, perceived degree of recovery, and the type of ICU were significant. For F2 Communication Modes, F3 Professional Behaviours, F4 Consequences, and NICSS total, the perceived degree of recovery and type of ICU had a statistically significant relationship to patient satisfaction (Table 4).
      Table 4Logistic regression models by factor and total NICSS.
      PredictorsEstimatesCIp-value
      F1. Holistic Care
      Intercept106.72103.61–109.83<0.001
      Standardised age (years)0.790.13–1.460.020∗
      Sex: male vs. female0.74−0.63–2.120.289
      Perceived degree of recovery0.950.56–1.34<0.001∗
      Specialised vs. polyvalent ICU−3.05−4.82–−1.280.001∗
      Observations676
      R2/R2 adjusted0.055/0.049
      F2. Communication Modes
      Intercept31.9931.00–32.97<0.001
      Standardised age (years)0.18−0.03–0.400.087
      Sex: male vs. female0.19−0.25–0.620.401
      Perceived degree of recovery0.290.17–0.41<0.001∗
      Specialised vs. polyvalent ICU−0.72−1.29–−0.160.011∗
      Observations676
      R2/R2 adjusted0.042/0.037
      F3. Professional Behaviours
      Intercept58.8457.26–60.42<0.001
      Standardised age (years)0.27−0.07–0.610.122
      Sex: male vs. female0.06−0.64–0.760.869
      Perceived degree of recovery0.560.37–0.76<0.001∗
      Specialised vs. polyvalent ICU−1.60−2.50–−0.700.001∗
      Observations676
      R2/R2 adjusted0.063/0.058
      F4. Consequences
      Intercept63.1261.03–65.20<0.001
      Standardised age (years)0.27−0.18–0.710.241
      Sex: male vs. female−0.46−1.38–0.460.326
      Perceived degree of recovery0.600.34–0.86<0.001∗
      Specialised vs. polyvalent ICU−2.30−3.48–−1.11<0.001∗
      Observations677
      R2/R2 adjusted0.053/0.048
      Total NICSS
      Intercept259.94252.70–267.18<0.001
      Standardised age (years)1.19−0.36–2.750.131
      Sex: male vs. female0.61−2.58–3.810.707
      Perceived degree of recovery2.281.38–3.18<0.001∗
      Specialised vs. polyvalent ICU−7.09−11.22–−2.970.001∗
      Observations676
      R2/R2 adjusted0.053/0.047
      NICSS, Nursing Intensive Care Satisfaction Scale.
      ∗p < 0.05.

      4. Discussion

      4.1 Satisfaction level

      The results of this study reveal that critical patients had very high levels of satisfaction with the nursing care received during their stay in the ICU. These results coincide with those of other research in which different instruments were used to assess satisfaction
      • Batbaatar E.
      • Dorjdagva J.
      • Luvsannyam A.
      • Savino M.
      • Amenta P.
      Determinants of patient satisfaction: a systematic review.
      ,
      • Crow R.
      • Gage H.
      • Hampson S.
      • Hart J.
      • Kimber A.
      • Storey L.
      • et al.
      The measurement of satisfaction with health care: implications for practice from a systematic review of the literature.
      and in which the same instrument was used.
      • Romero-García M.
      • Delgado-Hito P.
      • de la Cueva-Ariza L.
      • Martínez-Momblan M.A.
      • Lluch-Canut M.T.
      • Trujols-Albet J.
      • et al.
      Level of satisfaction of critical care patients regarding the nursing care received: correlation with sociodemographic and clinical variables.
      One explanation for elevated satisfaction levels may be social desirability bias, in which study participants give socially acceptable responses either as a result of continued use of different services or as the tendency to agree and respond positively.
      • Crow R.
      • Gage H.
      • Hampson S.
      • Hart J.
      • Kimber A.
      • Storey L.
      • et al.
      The measurement of satisfaction with health care: implications for practice from a systematic review of the literature.
      Several authors have suggested that fear of retaliation from negative responses may be the cause of the trend towards more favourable scores.
      • Acorn
      Patient satisfaction. Issues in measurement.
      Our study confirms the link between patient satisfaction and nursing actions identified in previous research. The link to pain management (item 6) has appeared in several studies.
      • Romero-García M.
      • Delgado-Hito P.
      • de la Cueva-Ariza L.
      • Martínez-Momblan M.A.
      • Lluch-Canut M.T.
      • Trujols-Albet J.
      • et al.
      Level of satisfaction of critical care patients regarding the nursing care received: correlation with sociodemographic and clinical variables.
      ,
      • Holanda M.S.
      • Talledo N.M.
      • Ots E.
      • Lanza J.M.
      • Ruiz A.
      • García A.
      • et al.
      Satisfaction in the intensive care unit (ICU). Patient opinion as a cornerstone.
      ,
      • Mosleh S.
      • Alja'afreh M.
      • Lee A.J.
      Patient and family/friend satisfaction in a sample of Jordanian Critical Care Units.
      Both Ayyub et al.
      • Ayyub R.
      • Kanji Z.
      • Dias J.
      • Roshan R.
      Perceptions of patients regarding quality nursing care (QNC) at a tertiary care hospital in Karachi, Pakistan.
      and Romero-GarcíaAuthor 1 et al.
      • Romero-García M.
      • Delgado-Hito P.
      • de la Cueva-Ariza L.
      • Martínez-Momblan M.A.
      • Lluch-Canut M.T.
      • Trujols-Albet J.
      • et al.
      Level of satisfaction of critical care patients regarding the nursing care received: correlation with sociodemographic and clinical variables.
      found links between patient satisfaction and timely administration of medication (item 7), the nurse's knowledge of how to proceed (item 9), the nurse's attentiveness (item 22), the nurse's emotional support (item 27), the nurse's ability to help the patient feel good (item 41), the nurse's concern for the patient's comfort (item 19), the relationship of trust (item 21), the nurse's paying attention to the patient (item 14), and the patient's desire to keep living (item 47).
      • Romero-García M.
      • Delgado-Hito P.
      • de la Cueva-Ariza L.
      • Martínez-Momblan M.A.
      • Lluch-Canut M.T.
      • Trujols-Albet J.
      • et al.
      Level of satisfaction of critical care patients regarding the nursing care received: correlation with sociodemographic and clinical variables.
      ,
      • Ayyub R.
      • Kanji Z.
      • Dias J.
      • Roshan R.
      Perceptions of patients regarding quality nursing care (QNC) at a tertiary care hospital in Karachi, Pakistan.
      As seen in other studies, patients highly valued receiving personal treatment from their nurse (item 31).
      • Romero-García M.
      • Delgado-Hito P.
      • de la Cueva-Ariza L.
      • Martínez-Momblan M.A.
      • Lluch-Canut M.T.
      • Trujols-Albet J.
      • et al.
      Level of satisfaction of critical care patients regarding the nursing care received: correlation with sociodemographic and clinical variables.
      ,
      • Gil-Juliá B.
      • Ballester-Arnal R.
      • Bernat-Adell M.D.
      • Giménez-García C.
      • Castro-Calvo J.
      Valoración de la estancia en UCI desde el punto de vista de pacientes y familiares [Assessment of ICU stay from the perspective of patients and relatives].
      The importance of technical skills (items 4 and 5) is also reflected in the literature.
      • Romero-García M.
      • de la Cueva-Ariza L.
      • Jover-Sancho C.
      • Delgado-Hito P.
      • Acosta-Mejuto B.
      • Sola-Ribo M.
      • et al.
      La percepción del paciente crítico sobre los cuidados enfermeros: una aproximación al concepto de satisfacción [Perception of the critical patient on nursing cares: an approach to the concept of satisfaction].
      ,
      • Romero-García M.
      • Delgado-Hito P.
      • de la Cueva-Ariza L.
      • Martínez-Momblan M.A.
      • Lluch-Canut M.T.
      • Trujols-Albet J.
      • et al.
      Level of satisfaction of critical care patients regarding the nursing care received: correlation with sociodemographic and clinical variables.
      ,
      • Gil-Juliá B.
      • Ballester-Arnal R.
      • Bernat-Adell M.D.
      • Giménez-García C.
      • Castro-Calvo J.
      Valoración de la estancia en UCI desde el punto de vista de pacientes y familiares [Assessment of ICU stay from the perspective of patients and relatives].
      Some authors show that technically more proficient care (item 3) may play an important role in increasing patient satisfaction.
      • Sanchez-Piedra C.A.
      • Prado-Galbarro F.J.
      • Garcia-Perez S.
      • Santamera A.S.
      Factors associated with patient satisfaction with primary care in Europe: results from the EUprimecare project.
      ,
      • Bjertnaes O.A.
      • Sjetne I.S.
      • Iversen H.H.
      Overall patient satisfaction with hospitals: effects of patient-reported experiences and fulfilment of expectations.
      ,
      • Senarath U.
      • Gunawardena N.S.
      • Sebastiampillai B.
      • Senanayake A.
      • Lekamge S.
      • Seneviratna A.
      • et al.
      Patient satisfaction with nursing care and related hospital services at the National Hospital of Sri Lanka.
      At the same time, care that lacks a human touch produces dissatisfaction in patients.
      • Goudarzi F.
      • Pour F.J.
      • Hasanvand S.
      • Ebrahimzadeh F.
      • Kvist T.
      Patients' satisfaction with humane care in critical care units.
      ,
      • Gorji H.A.
      • Etemadi M.
      • Hoseini F.
      Perceived organizational support and job involvement in the Iranian health care system: a case study of emergency room nurses in general hospitals.
      On the other hand, pain management (item 6),
      • Holanda M.S.
      • Talledo N.M.
      • Ots E.
      • Lanza J.M.
      • Ruiz A.
      • García A.
      • et al.
      Satisfaction in the intensive care unit (ICU). Patient opinion as a cornerstone.
      ,
      • Mosleh S.
      • Alja'afreh M.
      • Lee A.J.
      Patient and family/friend satisfaction in a sample of Jordanian Critical Care Units.
      kind nursing care (item 32), and interpersonal care increase satisfaction.
      • Crow R.
      • Gage H.
      • Hampson S.
      • Hart J.
      • Kimber A.
      • Storey L.
      • et al.
      The measurement of satisfaction with health care: implications for practice from a systematic review of the literature.
      ,
      • Sanchez-Piedra C.A.
      • Prado-Galbarro F.J.
      • Garcia-Perez S.
      • Santamera A.S.
      Factors associated with patient satisfaction with primary care in Europe: results from the EUprimecare project.
      ,
      • Ayyub R.
      • Kanji Z.
      • Dias J.
      • Roshan R.
      Perceptions of patients regarding quality nursing care (QNC) at a tertiary care hospital in Karachi, Pakistan.
      ,
      • Bjertnaes O.A.
      • Sjetne I.S.
      • Iversen H.H.
      Overall patient satisfaction with hospitals: effects of patient-reported experiences and fulfilment of expectations.
      Notably, high patient satisfaction is an indicator of high-quality nursing, which translates into a decrease in the average hospital stay and mortality, producing a decrease in costs.
      • Aiken L.H.
      • Sloane D.
      • Griffiths P.
      • Rafferty A.M.
      • Bruyneel L.
      • McHugh M.
      • et al.
      Nursing skill mix in European hospitals: cross-sectional study of the association with mortality, patient ratings, and quality of care.
      ,
      • Fenton J.J.
      • Jerant A.F.
      • Bertakis K.D.
      • Franks P.
      The cost of satisfaction: a national study of patient satisfaction, health care utilization, expenditures, and mortality.
      For most of our sample, the nurse-to-patient ratio was 1:2, which means that each nurse was responsible for two patients. Previous studies have found that a higher ratio of patients per nurse was associated with lower satisfaction and more negative health outcomes.
      • Karaca A.
      • Durna Z.
      Patient satisfaction with the quality of nursing care.
      ,
      • Aiken L.H.
      • Sloane D.
      • Griffiths P.
      • Rafferty A.M.
      • Bruyneel L.
      • McHugh M.
      • et al.
      Nursing skill mix in European hospitals: cross-sectional study of the association with mortality, patient ratings, and quality of care.

      4.2 Sociodemographic, clinical, and organisational variables

      The relationship of the variables analysed in terms of hours of invasive mechanical ventilation, perceived health status, perceived degree of recovery, level of complexity (secondary vs. tertiary), type of hospital (private vs. public), and the type of ICU (polyvalent vs. specialised) presented statistically significant differences. These results coincide with those of the study conducted by Rajabpour et al.
      • Rajabpour S.
      • Rayyani M.
      • Mangolian P.
      The relationship between Iranian patients' perception of holistic care and satisfaction with nursing care.
      in terms of hospital type. The fact that patients with higher satisfaction were those who were subjected to fewer hours on mechanical ventilation, who had higher perceived health status, who had a higher degree of perceived recovery, and who were treated at polyvalent ICUs of secondary level private hospitals may be explained by the less severe medical situation of patients in these circumstances.
      Age, sex, marital status, level of education, and length of ICU stay did not present statistically significant differences in relation to total patient satisfaction, as also shown in the review conducted by Batbaatar et al.
      • Batbaatar E.
      • Dorjdagva J.
      • Luvsannyam A.
      • Savino M.
      • Amenta P.
      Determinants of patient satisfaction: a systematic review.
      In addition, the results of our study coincide with those of other studies, in which there were no statistically significant differences between the overall level of satisfaction and age,
      • Abdel A.S.
      • Oweis A.I.
      • Hasna F.S.
      Differences between patients' expectations and satisfaction with nursing care in a private hospital in Jordan.
      ,
      • Goudarzi F.
      • Pour F.J.
      • Hasanvand S.
      • Ebrahimzadeh F.
      • Kvist T.
      Patients' satisfaction with humane care in critical care units.
      ,
      • Puch-Ku G.F.
      • Uicab-Pool G.Á.
      • Ruiz-Rodríguez M.
      • Castañeda-Hidalgo H.
      Dimensiones del cuidado de enfermería y la satisfacción del paciente adulto hospitalizado.
      sex,
      • Karaca A.
      • Durna Z.
      Patient satisfaction with the quality of nursing care.
      ,
      • Abdel A.S.
      • Oweis A.I.
      • Hasna F.S.
      Differences between patients' expectations and satisfaction with nursing care in a private hospital in Jordan.
      ,
      • Puch-Ku G.F.
      • Uicab-Pool G.Á.
      • Ruiz-Rodríguez M.
      • Castañeda-Hidalgo H.
      Dimensiones del cuidado de enfermería y la satisfacción del paciente adulto hospitalizado.
      marital status,
      • Abdel A.S.
      • Oweis A.I.
      • Hasna F.S.
      Differences between patients' expectations and satisfaction with nursing care in a private hospital in Jordan.
      education level,
      • Abdel A.S.
      • Oweis A.I.
      • Hasna F.S.
      Differences between patients' expectations and satisfaction with nursing care in a private hospital in Jordan.
      ,
      • Puch-Ku G.F.
      • Uicab-Pool G.Á.
      • Ruiz-Rodríguez M.
      • Castañeda-Hidalgo H.
      Dimensiones del cuidado de enfermería y la satisfacción del paciente adulto hospitalizado.
      length of ICU stay,
      • Abdel A.S.
      • Oweis A.I.
      • Hasna F.S.
      Differences between patients' expectations and satisfaction with nursing care in a private hospital in Jordan.
      and the type of patient cubicle.
      • Goudarzi F.
      • Pour F.J.
      • Hasanvand S.
      • Ebrahimzadeh F.
      • Kvist T.
      Patients' satisfaction with humane care in critical care units.
      Unlike in our study, other studies show that patients reporting higher satisfaction are those that are older,
      • Karaca A.
      • Durna Z.
      Patient satisfaction with the quality of nursing care.
      ,
      • Sanchez-Piedra C.A.
      • Prado-Galbarro F.J.
      • Garcia-Perez S.
      • Santamera A.S.
      Factors associated with patient satisfaction with primary care in Europe: results from the EUprimecare project.
      have less education,
      • Karaca A.
      • Durna Z.
      Patient satisfaction with the quality of nursing care.
      ,
      • Rajabpour S.
      • Rayyani M.
      • Mangolian P.
      The relationship between Iranian patients' perception of holistic care and satisfaction with nursing care.
      and/or have a shorter ICU stay.
      • Goudarzi F.
      • Pour F.J.
      • Hasanvand S.
      • Ebrahimzadeh F.
      • Kvist T.
      Patients' satisfaction with humane care in critical care units.
      Our results coincide with those of other authors who show a statistically significant correlation between, on the one hand, patient satisfaction, and, on the other, perceived health status
      • Karaca A.
      • Durna Z.
      Patient satisfaction with the quality of nursing care.
      ,
      • Abdel A.S.
      • Oweis A.I.
      • Hasna F.S.
      Differences between patients' expectations and satisfaction with nursing care in a private hospital in Jordan.
      and perceived degree of recovery.
      • Abdel A.S.
      • Oweis A.I.
      • Hasna F.S.
      Differences between patients' expectations and satisfaction with nursing care in a private hospital in Jordan.
      While other studies found a significant relationship between patient satisfaction and cubicle type,
      • Mosleh S.
      • Alja'afreh M.
      • Lee A.J.
      Patient and family/friend satisfaction in a sample of Jordanian Critical Care Units.
      ,
      • Hunziker S.
      • McHugh W.
      • Sarnoff-Lee B.
      • Cannistraro S.
      • Ngo L.
      • Marcantonio E.
      • et al.
      Predictors and correlates of dissatisfaction with intensive care.
      ,
      • Schwarzkopf D.
      • Behrend S.
      • Skupin H.
      • Westermann I.
      • Riedemann N.C.
      • Pfeifer R.
      • et al.
      Family satisfaction in the intensive care unit: a quantitative and qualitative analysis.
      we did not. Finally, the logistic regression model shows that the variables that predict satisfaction for individual factors and/or for the total NICSS are age, degree of recovery, and the type of ICU.
      Although the NICSS scores are high, there is still room for improvement, and this study makes it possible to identify priorities. Ongoing use of the NICSS could provide baseline data for improving nursing management and the quality of care. For example, patients’ need for rest (item 16) could be better addressed through dimmable lighting, noise detectors, and the consolidation of nighttime care into shorter periods to minimise interruptions.
      • Beck Edvardsen J.
      • Hetmann F.
      Promoting sleep in the intensive care unit.
      ,
      • Devlin J.W.
      • Skrobik Y.
      • Gélinas C.
      • Needham D.M.
      • Slooter A.J.C.
      • Pandharipande P.P.
      • et al.
      Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU.

      4.3 Limitations

      This study has several limitations. There may be a survival bias because patients who died could obviously not be included in the study. It is also possible that dissatisfied patients opted not to participate in the study. The lack of variability in the responses (observed in the concentration of responses in the highest scores of the items and dimensions) meant that we did not have a wide range of data for analysis covering all potential scores. High scores may reflect social desirability.

      5. Conclusion

      Critical patients presented very high levels of satisfaction with the nursing care received during their stay in the ICU for the total scale and for each of the factors. The sociodemographic variables of the study sample did not present statistically significant relationships with the mean score in any of the subgroups. Previous studies showed that patient satisfaction is related to the perception of health status and the perception of the degree of recovery. We confirm these findings and show that patient satisfaction is also correlated with the hours of mechanical ventilation, hospital complexity, hospital type, and ICU type. These findings should be considered not only in clinical practice but also in ICU planning and management because they highlight areas for improvement.

      Funding

      This study had been funded by the Nurse and Society Foundation (PR-282/18) as part of the Nurse Research Projects Grants (PR-282/18) and the Carlos III Health Institute (Ministry of Science and Innovation) (PI18/00935) and co-financed by the European Regional Development Fund, whose motto is “A way to build Europe”, FIS (PI18/00935).

      CRediT authorship contribution statement

      Pilar Delgado-Hito: Conceptualisation, Methodology, Supervision, Project administration, Formal analysis, Writing e original draft, Writing e review and editing.
      Isidro Alcalà-Jimenez: Methodology, Data curation, Software, Writing e review and editing.
      María Antonia Martínez-Momblan: Writing, review and editing.
      Laura de la Cueva-Ariza: Writing review and editing.
      Jordi Adamuz: Writing, review and editing.
      Cecilia Cuzco: Writing, review and editing.
      Llúcia Benito-Aracil: Conceptualisation, Methodology, Formal analysis, Writing e original draft, Writing e review and editing.
      Marta Romero-García: Conceptualisation, Methodology, Supervision, Project administration, Formal analysis, Writing e original draft, Writing e review and editing.

      Conflict of interest

      None.

      Acknowledgements

      We thank the patients for their help, patience, and participation and also all of the collaborating researchers of the participating hospitals. Susan Frekko provided feedback on the manuscript and translated it from the original Spanish. We thank the CERCA Programme/Generalitat de Catalunya for institutional support.

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