Relationship between nurses’ motivation and patients’ satisfaction in dialysis units in Minia city

Introduction

Today, healthcare sector is facing stiff competition and an increasing expectation from the patients. Patients are viewing healthcare services from different angles and perspectives. Standard of healthcare services has been emphasized tremendously owing to the rising consumer affluence and well-informed patients towards the quality and delivery of healthcare services (Hee & Kamaludin, 2016).

So motivation plays an important role in retaining healthcare personnel. This in turn increases productivity of the health care systems which is manifested in patients’ outcomes. There are several motivational patterns in the nursing profession such rewards, relationship, challenge, control and drive. Patient satisfaction, quality of life, symptoms, morbidity and mortality are some of the patient outcomes in the health care service (Kantek et al., 2015).

In healthcare organization, work motivation is an important measure of healthcare professional’s response to the increasing challenges and demands. Motivation is known as a process that starts with an inspiration to perform and energized to an end. It initiates behaviours to accomplish the intended goals. Motivationis a complex, multidimensional and therefore defined as "the force within individual that influence or direct behaviour (Baljoon et al., 2018).

Moreover motivation is a concept used to describe an external state inspiring a specialbehavior and internal responses revealing that behaviour. In the organizational context, motivation is explained as the stimulus of work behaviour, which channels the worker’s effort to accomplish the organization’s goals. Worker motivation is the result of the interactions between individuals (internal psychological process),their work environment (a transactional process) and the fit between these interactions and the societal context (Hee & Kamaludin, 2016).

Extrinsic motivation (EM) is an exterior force that leads workers to meet personal and organizational aims. Moreover, it guides persons to carry out responsibilities by using coercion or instruction to get rewards in return. Extrinsic rewards consist of awards, bonuses, pay and benefits. It also can be in the forms of good relationship between workers, better facilities, good working conditions and higher administrator’s quality at the work area. Extrinsic motivation in the healthcare context leads the nurses to achieve work behaviors such as prizes, positions, awards, incentives and numerous fringe benefits which generated by external stimuli and profit themselves and their organization (Papathanasiou       et al., 2014).

 So motivation is the willingness to put effort into achieving a goal or reward to decrease the tension caused by need. Motivated human resources are the most important assets of any health system. This resource, especially nursing department works directly with the health consumers (patients). Once the nurses are motivated, the work productivity increases resulting in good outcome which is good patients’ outcomes. In recent years it has been increasingly recognized that improving the motivation of health personnel should be at the core of any sustainable solution to patient outcome (Demirhan, 2020).

Patient satisfaction with medical care is a multidimensional concept, with a dimension that corresponds to the major characteristics of providers and services. Within the health care hospital, patient satisfaction can be considered as an important component and measure of the quality of care. Patient satisfaction is a cumulative construct which embraces satisfaction with various hospital facilities such as technical, functional, interaction and atmosphere. Patient satisfaction plays an important role in the continuity of service utilization and positively influences the patient’s trust (Bakan et al., 2014).

Patients’ satisfaction reflects patients’ perceptions and needs towards health service utilization. Assessing patients’ satisfaction is an important since it often helps, in absence of healthcare service quality indicators, to determine the quality of health-care delivery and health system responsiveness (Batbaatar et al., 2015).

Higher levels of patients’ satisfaction indicate higher levels of patient empowerment, commitment to care and compliance to recommended management–all of which results in better health outcomes. Measuring patients’ satisfaction also helps to improve service delivery and to prioritize capacity building needs and resource distribution. Previous studies looked into this topic either from quality of care perspectives or from healthcare system perspectives (Adhikary et al., 2018).  

Moreover chronic diseases have received increased attention from health professionals by presenting high rate of morbidity and mortality rates. Thus, it becomes a major concern for the public health field. Among the many chronic diseases that affect the population, Chronic Kidney Disease (CKD) is considered a pathology without expectation of the cure, with rapidly and progressive evolution, triggering diverse reactions for patients and compromise the quality of life (QOL). This disease is present in a large number of people and has a gradual and irreversible evolution, generating complications and disorders for patients (McCrory et al., 2018).  

So dialysis care nursing is one of the developing disciplines because more and more nurses are venturing into the field. This field requires nurses who are highly knowledgeable and skilled for the care of patients with Chronic Kidney Disease. Technological and educational advances make it a dynamic field, rich with a wide variety of career opportunities for a new graduate or an experienced practitioner (Moffatt et al., 2018).

Significance of the study

During the researcher work in Minia General Hospital,  observed that dialysis nurses had frustration in their work manifested with repeated absenteeism from work, un-thinking in new ideas associated with dialysis, committed a lot of mistakes and  taking many functional sanctions which lead to patient’s dissatisfaction. So, it is helpful to investigate the relationship between nurses’ motivation and patients’ satisfaction.

 Over the last years, Patient satisfaction has been increasingly used as one indicator of the quality of health care. Measurement of patient satisfaction is used to compare health care programs and to evaluate quality of care and to identify which aspect of a service need improvement suggested that patient satisfaction is an important and widely accepted measure of care efficiency(Simeza, 2013). 

There were no previous studies which linked those two interrelated variables together, but Aly and  El-Shanawany, (2016) studied the influence of performance appraisal satisfaction on nurses' motivation and their work outcomes in critical care and toxicology units,  the study conducted on14 critical care and toxicology units within the Alexandria University Hospitals and indicated that nurses’ intrinsic motivation had a highly significant positive relationship with nurses’ work outcomes. while Fouad et al., (2020) studied nurses compliance toward patients' rights and its relation to patients satisfaction,  the study conducted at  Minia and indicated that more than half of staff nurses had high level of compliance toward patients' rights and low half of patients responded toward high level of satisfaction at Minia University Hospital

 Moreover Simeza,. (2013) studied Impact of nurses’ motivation on patients’ outcomes: a case study of renal unit at Kenyatta National Hospital (KNH). The study revealed that nurses in renal unit of KNH are motivated with achievement, recognition, autonomy and renumeration. The patients were satisfied with nurses’ good listening skills, being treated as individuals, nurses’ responsiveness, and provision of information.

Aim of the study

The study aim to assess relation between nurses’ motivation and patients’ satisfaction in dialysis units with the following specific aims :

• To assess the patient’ satisfaction in dialysis units.
• To determine the motivational factors of nurses working in dialysis units.
• To examine the relationship between nurses motivation and patient satisfaction.

Research questions

• How to reach patients’ satisfaction in dialysis units?
• What are the motivation factors of nurses working in dialysis units?
• Is there a relationship between nurses motivation and patient satisfaction?

SUBJECTS and METHOD

Research Design

Cross sectional descriptive correlational research design that was carried out in the present study.

Setting

           The study was conducted at Dialysis Units in Minia General Hospital, Minia University Hospital and Health Insurance Hospital.

Subjects

Convenience sample, the study subject were including nurses and patients in dialysis units with total number 83 nurse and patients included  through six months across the three hospitals as follows:

Tools of Data Collection

Two tools were used in this study as follows: Motivation factors scale  for nurses and Patient's satisfaction scale

1^sttool:

Semi-structured questionnaire for nurses was used to assess the motivational levels available in the unit; this tool was included two parts as follows:  

Part I: Socio demographics data

Socio demographics data sheet for studied nurses.  It was including; (age, gender, hospital name, educational level, schedule, marital status, die patients, and residence).

Part II  : Motivation factors of nurses scale

The study tool had   been operationalized by the researcher to suit the study with some information being modified from Whitaker, (2011) motivation scale.  The modification such change 5 points Likert scale to three points (disagree=1; uncertain=2; agree=3). The motivation factors of nurses scale is self-administered. The scale consists of 19 questions attempted to determine the motivational factors for nurses and one open question for suggestions and recommendations to overall motivation levels in their department.

Scoring system:                      

                           The scoring system of this tool was classified into 3 levels as a follow: Low motivation factors of nurses ranged as (19-31), Moderate motivation factors of nurses ranged as (32-44) and High motivation factors of nurses ranged as (45-57)

2^ndtool:

 A semi - structured questionnaires were also used to collect data from the patient. This tool was included two parts as follows:  

Part I: Socio demographics data

Socio demographics data sheet for studied patients.  It was including; (age, gender, hospital name, educational level, Hospital length of stay, and marital status).

Part II: Patient's satisfaction scale

This tool developed by Laschinger, (2008) and was (adopted) by the researcher and translated into Arabic to assess patient's satisfaction. It include 21 questions attempt to determine patients satisfaction, each question was measured using three-points Likert scale (1= Poor, 2= fair 3= good) and finally content one open question for suggestions and recommendations that enhance patient satisfaction

Scoring system:                      

The scoring system of this tool was classified into 3 levels as a follow: Low patient satisfaction ranged as (21-35), Moderate patient satisfaction ranged as (36-49) and High patient satisfaction ranged as(50-63)

Validity of the study tools:

Tools were tested for the content validity by a jury of three experts in the field of Nursing Administration and necessary modifications were done. The jury composed of three Assistant Professors from Faculty of Nursing, Minia University.  Each of the expert panel was asked to examine the instruments for content coverage, clarity, wording, length, format and overall appearance.

Reliability of the study tools

Reliability of the tools was performed to confirm consistency of tools. The internal consistency measured to identify the extent to which the items of the tools measured the same concept and correlate with each other by Cronbach’s alpha test that revealed good internal reliability for the tools; and distributed as follows:

Pilot Study:

• A pilot study was conducted on 10% of participants as (8) of staff nurses and (45) of patients to ascertain the clarity, comprehensiveness and applicability of the tools as well as to estimate the appropriate time required to fill the scale. Based on pilot study there was no modification done, and it was added to final results.
• The main purposes of the pilot study were to:
  • Test the data collection tools regarding the phrasing, and the need for adding or omitting or items for each tool
  • Determine difficulties that could arise and solutions to deal with them
  • Estimate time required filling the tool; it was about 10 to 15 minutes for each tool.

Data Collection Procedures:

• Official letters to obtain the approval were introduced to Faculty Dean; this letter was included a brief explanation of the objectives of the study.
• Written approvals were obtained from Directors of the three included Hospitals, and head nurses of Hospitals after explaining the purpose of the study.
• Tools were adopted and translated into Arabic; then collect the jury approval for the tools to collect data of the study.
• The tools were distributed to all the participants after explaining the purpose and process of data collection. Tools were directly administered and supervised by the researcher.
• The researcher interviewed with study participants through morning and evening shift during the working days. 
• Participants were given from 15 minute to 30 minute to answer all the tools. They were allowed to discuss with researcher any question that needs more clarification. 
• The data collection was performed from staff nurses and patients of three hospitals during the period of 6 months from the beginning of October 2018 to end of March 2019. 

Administrative design:

• A written initial approval was obtained from the research ethics committee of the Faculty of Nursing, Minia University.
• An official letter was granted from Faculty Dean, the Director of the included Hospitals, and Nursing Director Hospitals

Ethical Considerations:

• The participants (staff nurses and patients) were informed that their participation in the study was completely voluntary and there was no harm if they not participate in the study.
• Oral consent was obtained from head nurses and staff nurses after explaining the nature and benefits of the study.
• The participants assured that the data of this research will not be reused without second permission. Anonymity and confidentiality were assured .

Statistical analysis of data

Data were summarized, tabulated, and presented using descriptive statistics in the form of frequency distribution, percentages, means and the standard deviations as a measure of dispersion. A statistical package for the social science (SPSS), version (20) was used for statistical analysis of the data, as it contains the test of significance given in standard statistical books. Numerical data were expressed as mean and SD. Qualitative data were expressed as frequency and percentage. Probability (P-value) is the degree of significance, less than 0.05 was considered significant. The smaller the P-value obtained, the more significant is the result (*), less than 0.001 was considered highly significant (**) and correlation coefficient was done by using Pearson correlation test. ANOVA test was used to compare two different mean among study and control group in the current study. Fisher's exact test: they are alternatives for the Pearson’s chi square test if there were many small expected values.

Results

Table (1) distribution of the nurses staff regarding to their personal data (no. =83).

Table (1) illustrates that  according Minia General Hospital (75.9%) of nurses age are ranged from 20-

Concerning Health Insurance Hospital, (39.2%) of nurses age are ranged from 20-

Figure (1) explains that (37.8%) of nurses' recommendations regarding their motivational factors at Minia General Hospital increase the salary, and (20.8%) of the share in decision.  While figure (2) mentions that the high percent (41.9%) of nurses' recommendations regarding their motivational factors at Minia University Hospital provide training and (35.5%) of them increase the salary. Moreover figure (3) mentions that the high percent (39.2%) of nurses' recommendations regarding their motivational factors at Health Insurance Hospital provide increase number of staff nurses, and (30.4%) of them increase the salary.

Figure  (4) show that the most of nurses' suggestions regarding their motivational factors at Minia General Hospital are increase equipment and supplies as (44.80%), while (41.40%) of them need respect from supervisors. Figure (5) explains that the most of nurses' suggestions regarding their motivational factors at Minia UniversityHospital are provide effective and efficient equipment as (48.4%), while (22.6%) of them need for increasing number of staff nurses.  Moreover figure (6) discuss  that the most of nurses' suggestions regarding their motivational factors at Health Insurance Hospital are provide effective and efficient equipment as (56.5%), while (39.2%) of them need for continuous learning. 

Figure (7) percentage distribution of nurses' motivational factors in selected Hospitals   (no. =83)

Figure (7) shows that the majority of nurses (96.8%) have moderate level of motivational factors at Minia University Hospital follow by nurses in Health Insurance Hospital as (95.7%), and finally nurses in Minia Hospital as (75.9%). 

Figure (8) percentage distribution of nurses' total motivational factors in selected Hospitals (no. =83)

Figure (8) explains that the majority of nurses (89.2%) have moderate level of motivational factors in selected Hospitals, while (10.8%) of them has high level of motivational factors.

Table (4) indicates that  the high percent of patient's opinions regarding their satisfaction at Minia General Hospital in favor to good response for the items  (the nurse was explaining clearly what I was supposed to do; the nurse was honest about my condition; and the nurse was genuinely concerned with my situation) as (72.1%;66%; and 64.6%) respectively, while  (46.9%) of them poor response  for item (looking at the notes or computer or anything around herself). Also the high percent of patient's opinions regarding their satisfaction at Minia UniversityHospital in favor to good response for the items (the nurse communicated that he/she had accurately understood my concerns; and the nurse was fully answering my questions) as (71.3%and 70.7%) respectively, while  (34%) of them poor response  for item (the nurse was giving me true and adequate information).

Moreover the high percent of patient's 'opinions regarding their satisfaction at Health  InsuranceHospital in favor to good response for the items (the nurse was positively approaching me with positive attitudes; the nurse communicated that he/she had accurately understood my concerns; and the nurse addressed me with my name not just as "just a number") as (69.4%; 68.7;%and 68%) respectively, while  (60.7%) of them poor response  for item (looking at the notes or computer or anything around herself).

Figure (9) illustrates that most   recommendations of patients regarding their satisfaction at Minia General Hospital are " communication with nurses; respect from nurses and share in decision making) as (39.20%, 22.20%, 21%) respectively. Figure (10) illustrates that most   recommendations of patients regarding their satisfaction at Minia University Hospital are   " communication with nurses; honest about their conditions and respect from them) as (30.70%, 27.30%, &26%) respectively. Moreover figure (11) illustrates that most   recommendations of patients regarding their satisfaction at Health Insurance Hospital are " honest about their conditions; share in decision making and respect) as (30.70%, 27.30%, &25.3%) respectively.

Figure (12) illustrates that most   suggestionsof patients regarding their satisfaction at Minia General Hospital are " the nurses should encourage them for expression their feeling; discuss with them their health status; and give them formations about health status) as (34.6%, 25 % & 19.9%) respectively. Moreover figure (13) illustrates that most suggestionsof patients regarding their satisfaction at Minia University Hospital are  " the nurses should answer their questions truly; discuss with them their health status; and nurses encourage them as (34.7%, 26 % & 23.3%) respectively. Figure (14) illustrates that most   suggestionsof patients regarding their satisfaction at Health Insurance Hospital are " the nurses should answer their questions; give information them about their health status; and nurses encourage them) as (34.7%, 27.3 % & 20%) respectively.

Figure (15) percentage distribution of patient's satisfaction at selected Hospitals   (no. =447)

Figure (3) shows that the high percent of patients(76.7%) have moderate level of satisfaction in Minia University Hospital follow by patients  in Minia General Hospital as (66.7%),and finally patients  in Health Insurance Hospital  as (54.7%). 

Figure  (16) percentage distribution of patient's total satisfaction at selected Hospitals   (no.=447)

Figure (4) explains that the majority of patients (66%) have moderate level of satisfaction in selected Hospitals, while (34%) of them have high level of satisfaction. 

Table (5) correlation between nurses' motivational factor and patient's satisfaction

**Correlation is significant at the 0.01 level (2-tailed). * p≤0.05 (significant) **p≤0.05 (highly significant),PCC: P – value based on Pearson correlation coefficient

Table (5) explains that there is a positive correlation between nurses'motivational factor and patients' satisfaction (p =.004**)