Discussion: Qualitative Analysis on Patient Satisfaction with Maternity Wards

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BMC Pregnancy and Childbirth 2013, 13:108 http://www.biomedcentral.com/1471-2393/13/108 RESEARCH ARTICLE Open Access Measures of satisfaction with care during labour and birth: a comparative review Alexandra Sawyer1, Susan Ayers2*, Jane Abbott3, Gillian Gyte4, Heike Rabe5 and Lelia Duley6 Abstract Background: Satisfaction is the one of the most frequently reported outcome measures for quality of care. Assessment of satisfaction with maternity services is crucial, and psychometrically sound measures are needed if this is to inform health practices. This paper comparatively reviews current measures of satisfaction with care during labour and birth. Methods: A review of the literature was conducted. Studies were located through computerised databases and hand searching references of identified articles and reviews. Inclusion criteria were that the questionnaire was a multi-item scale of satisfaction with care during labour and birth, and some form of psychometric information (either information about questionnaire construction, or reliability, or validity) had to be reported. Results: Nine questionnaires of satisfaction with care during labour and birth were identified. Instruments varied in psychometric properties and dimensions. Most described questionnaire construction and tested some form of reliability and validity. Measures were generally not based on the main theoretical models of satisfaction and varied in scope and application to different types of samples (e.g. satisfaction following caesarean section). For an in-depth measure of satisfaction with intrapartum care, the Intrapartal-Specific Quality from the Patient’s Perspective questionnaire (QPP-I) is recommended. Brief measures with good reliability and validity are provided by the Six Simple Questions (SSQ) or Perceptions of Care Adjective Checklist (PCACL-R). Conclusions: Despite the interest in measures of satisfaction there are only a small number of validated measures of satisfaction with care during labour and birth. It is important that brief, reliable and valid measures are available for use in general and specific populations in order to assist research and inform practice. Keywords: Patient satisfaction, Labour, Birth, Questionnaire, Measurement Background Satisfaction is the of the most frequently reported outcome measures for quality of care [1] and enhanced satisfaction has been identified as a goal for improvement in health care.Discussion: Qualitative Analysis on Patient Satisfaction with Maternity Wards [2] Women’s satisfaction with maternity services, especially care during labour and birth, has become increasingly important to healthcare providers, administrators, and policy makers [3,4]. Research shows that women’s satisfaction with childbirth is partly related to the health and well-being of the mother and her baby. For example, dissatisfaction is associated with poorer postnatal psychological adjustment, a higher rate of future abortions, preference for a caesarean section, more * Correspondence: [email protected] 2 School of Health Sciences, City University London, 20 Bartholomew Close, London, UK Full list of author information is available at the end of the article negative feelings towards the infant and breast-feeding problems [1,5,6]. However, the concept of satisfaction is complex and poorly defined [7]. A definition suggested by Ware et al. [8] is that an individual’s satisfaction with healthcare is a “personal evaluation of healthcare services and providers” (p.247). These evaluations reflect the personal preferences of the individual, the individual’s expectations, and the realities of the care received. Linder-Pelz and Struening [9] provide a similar definition noting that satisfaction comprises of “multiple evaluations of distinct aspects of healthcare which are determined (in some way) by the individual’s perceptions, attitudes and comparison processes” (p. 42). This definition highlights the multidimensional nature of satisfaction. © 2013 Sawyer et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Sawyer et al. BMC Pregnancy and Childbirth 2013, 13:108 http://www.biomedcentral.com/1471-2393/13/108 Several theories of people’s satisfaction with healthcare have been developed [10]. The majority of studies on people’s satisfaction are based on fulfilment or discrepancy theories [3,11]. Fulfilment theories state that a person’s satisfaction is determined by the outcome of the experience, and previous expectations are not important. In comparison, discrepancy theories argue that a person’s satisfaction is determined by the differences between what is expected and what actually happens. Theories of people’s satisfaction can be used to inform the development of measures of satisfaction. However, the extent to which this is the case for measures of satisfaction with labour and birth is not clear. The importance of assessing satisfaction when evaluating healthcare services means it is also imperative that reliable and valid measures are used [4]. Discussion: Qualitative Analysis on Patient Satisfaction with Maternity Wards Surveys are the most common method of assessing individual’s experiences of care in research, evaluation, and audits. Although satisfaction surveys are vital tools for accessing a person’s views, and can form an integral part of assessing the quality of care and informing service planning, they have not always been conducted with the necessary methodological rigour [4]. Firstly, many surveys only use a single item to assess satisfaction with care, which ignores the multidimensional quality of satisfaction [11,12]. For example, research looking at satisfaction with maternity care suggests the following dimensions are important: staff-woman interaction, information, involvement in decision making, pain relief, and birth environment [3,13-15]. Secondly, surveys of satisfaction with maternity services have been criticised for not being developed on the basis of theory [16]. Sitzia and Wood [7] argue that conceptual and theoretical issues should underpin the design and structure of a methodology. Thirdly, satisfaction measures in general have been criticised for being poorly constructed along with having poor psychometric properties including reliability and validity [17,18]. It is therefore evident that psychometrically sound measures are needed to appropriately evaluate satisfaction with care during labour and birth. However, available measures of satisfaction with childbirth are diverse and range from single item measures to extensive surveys of all aspects of maternity care. Measures do not always differentiate between the experience of labour and birth (such as pain and negative emotions) and the experience of care [17,19]. Therefore many research studies have created their own scales, with little or no psychometric evaluation. This has resulted in a confusing array of available measures that vary in content and quality. There is currently no review of questionnaires used to measure satisfaction with care during labour and birth. This paper therefore reviews current published measures of satisfaction with care during labour and birth. More specifically this review aimed to identify instruments which measure satisfaction Page 2 of 10 with labour and birth; and to evaluate the psychometric properties of these questionnaires. Methods Criteria for selecting potentially eligible studies Studies were included if they reported use of a questionnaire that was a multi-item scale of satisfaction with care during labour and birth, and provided psychometric information (either about questionnaire construction, or reliability, or validity) Discussion: Qualitative Analysis on Patient Satisfaction with Maternity Wards for the satisfaction measure. Studies were excluded if they reported questionnaires that: (1) described an omnibus measure to assess satisfaction with maternity services overall (e.g. antenatal, birth, and postnatal); (2) included items that were not specific to labour/birth; (3) were qualitative assessments of birth satisfaction; (4) were developed specifically for fathers; (5) comprised of dissertations, nonoriginal research (i.e. reviews, opinion papers), or conference presentations; and (6) were not written in English. Search strategy A systematic search was conducted to identify potentially eligible studies using the search terms: (Birth or Childbirth or Lab*r or Intrapart*) AND (Satisfaction or Perception or Evaluation) AND (Questionnaire or Measure* or Scale or Instrument). The databases Scopus, PsychArticles, PsychInfo, PubMed, and Web of Science were searched up to 30 July 2011. Reference lists in reports of included studies were searched for additional studies. Citations identified in this search strategy were then checked electronically to identify and remove duplicates. Finally, the Web of Knowledge and Scopus were searched for all reports that cited the final questionnaire measures. No new citations were identified. Selection of studies and data extraction Titles and abstracts (where available) for each citation were screened by one review author (AS) and those clearly not eligible were excluded. Full text reports were retrieved for the remaining citations. These were screened for inclusion by independently by two review authors (AS and SA). For excluded studies, reasons for exclusion were recorded. For included studies, data were extracted onto a prepared data extraction form by AS, and checked by SA. Data extraction included: the satisfaction measure used, format of the questionnaire, country where study was conducted, sample, and questionnaire construction, reliability and validity. Assessment of psychometric quality Psychometric quality of each questionnaire was assessed using the following criteria: Questionnaire construction Item generation – this phase is undertaken to develop a pool of items that should include all Sawyer et al. BMC Pregnancy and Childbirth 2013, 13:108 http://www.biomedcentral.com/1471-2393/13/108 important elements of satisfaction by reviewing existing questionnaires, literature, opinions from maternity care-providers and focus groups of mothers. Items taken directly from women represent what they truly value and opinions from providers can ensure that significant elements of care have not been missed [20]. Pilot study – the process of pre-test and pilot testing of the final questionnaire by using the response from the pre-test group to make revisions to the final version. Items with ambiguous meanings can be eliminated to maximise the reliability and validity of the questionnaire. The questionnaire should then be re-administered and tested in a new sample [20]. Page 3 of 10 Reliability – the ability of a measure to produce consistent results Internal consistency – refers to the extent to which items in a questionnaire are measuring the same things. One method of assessing internal consistency is using Cronbach’s alpha (?) and a minimum value of 0.70 is considered reliable [21]. Test–retest reliability – refers to the ability of a test to yield consistent scores over time. It is recommended that a minimum value of 0.70 is considered reliable [22]. Discussion: Qualitative Analysis on Patient Satisfaction with Maternity Wards Validity –the extent a questionnaire measures what it is supposed to measure Content validity – whether an instrument adequately covers the domains to be evaluated. The development of a content valid instrument is typically achieved by analysis of the instrument by raters familiar with the construct of interest. Content validity can also be assessed by focus group participants and review of the literature. Another source of evidence can be obtained from how the measure was initially developed. Face validity – is closely related to content validity and refers to whether a measure appears to be measuring what it is supposed to measure. One method of assessing face validity is to administer the measure to participants and professionals for subjective opinion. Evidence can also be obtained from how the measure was initially developed. Criterion validity – considers whether scores from the questionnaire correlate with the definitive standard measurement of the same outcome. However, there is no definitive standard for measuring satisfaction in any previous study. A possible exception may be when a longer version of a questionnaire is used as the ‘gold standard’ to develop a shorter version of the same established instrument [22,23]. When no criterion is available it is possible to examine construct validity. Construct validity – can be used when some attribute (i.e. satisfaction) is not “operationally defined.” There are many different methods to assess construct validity: Group differences – if the understanding of a construct leads to the assumption that groups could differ on the test, this expectation may be tested directly. For example it might be expected that women who experienced low support during birth might have lower patient satisfaction scores. Convergent validity – if a test has construct validity then it is expected that test scores will correlate with scores on other tests that measure a similar construct. Discriminant validity – this is the opposite of convergent validity. If different constructs are not considered to be related then there should be no correlation between test scores measuring these different constructs. Factorial validity – examination of the internal structure of scales and the ability of the construct to provide a clear factor structure. No statistaical analysis was planned. Results In total 17,823 citations were identified in the search strategy (Figure 1). After de-duplication and screening of titles and abstracts full text copies were retrieved for 453 citations, of which 439 were excluded. The 14 included studies reported nine measures of satisfaction with care during labour and birth. These studies and the questionnaires are described in Additional file 1 Table S1. For seven questionnaires detail about how the items were selected was reported, and for six a pilot study of the questionnaire was described. Most of the questionnaires (8 out of 9) had tests of internal consistency, but only one reported test-retest reliability [15]. All studies reported on at least one aspect of validity. No study reported criterion validity of the measure. The following section provides a description of each questionnaire and a summary of its psychometric properties. Six Simple Questions (SSQ) The SSQ [5] is a brief, easily administered questionnaire of satisfaction with care during childbirth. Discussion: Qualitative Analysis on Patient Satisfaction with Maternity Wards The questionnaire has high reliability (? = 0.86). Face validity and content validity is suggested by the questionnaire development, as items were reviewed by the authors who developed the questionnaire and assessed it for congruence with the literature. Also, the questionnaire was Sawyer et al. BMC Pregnancy and Childbirth 2013, 13:108 http://www.biomedcentral.com/1471-2393/13/108 Page 4 of 10 Citations identified (n=17823) database search (17759) other sources (64) Duplicates (n= 5458) Titles and abstracts inspected (N= 12365) Excluded (n = 11912) Full text retrieved (n = 453) Studies included (n= 14) Excluded (n = 439) Reasons: conference abstract (2) dissertation (7) fathers only (5) non-English (41) qualitative (71) discussion or opinion paper (22) not specific to birth (80) data repeated (4) not for postnatal women (9) no psychometric information (4) not relevant after full inspection (55) no measure of satisfaction with care (105) insufficient information (5) single item measure (24) unavailable (5) Separate questionnaire measures (n = 9) Figure 1 Flow chart. administered initially to a small group of women to check clarity of language and ease of administration. Construct validity is suggested by moderate to strong correlation (r = 0.51) with another measure, the Labour and Delivery Satisfaction Index (LADSI) [15] (see below), and the finding that women were more satisfied with their care if it was provided by midwives rather than by doctors. The authors used the SSQ to measure satisfaction with childbirth at 48 hours, 2 weeks and 6 weeks postpartum. However, they do not report the correlations between these time points, which would have provided a useful indicator of test-retest reliability. The SSQ has high reliability and there is evidence of reasonable face validity and content validity; as well as good construct validity. A limitation is that it uses an overall single score for satisfaction, so satisfaction with specific aspects of care cannot be explored. Consumer Satisfaction Questionnaire (CSQ) The CSQ [24] is a 17-item questionnaire developed to measure couples’ perceptions of care during labour and birth. Content and face validity is suggested by the questionnaire development because items were developed from a review of the literature, parent interviews and a pre-test with 20 couples. Factorial validity was established through principal components analysis, which identified three clear factors of satisfaction: supply of equipment; participants in the labour and birth; management of the ward. Together these factors accounted for 65% of the variance. Construct validity is suggested as satisfaction with healthcare was positively associated with social support (r = 0.36), especially with medical staff support. Internal consistency for the questionnaire was high (? = 0.93). The CSQ appears to be reliable and have good face, content and construct validity. However, it has significant limitations. It was developed and validated in Taiwan and, although it is reported in English, has not been validated outside of Taiwan. In addition, the CSQ was validated with couples who had a healthy baby born at 37+ weeks gestation with an uncomplicated vaginal birth. This means it may not be applicable to more complicated births, or births in Western cultures. Labour and Delivery Satisfaction Index (LADSI) The LADSI [15] is a 38-item questionnaire which measures the “technical” and “caring” components of satisfaction. Discussion: Qualitative Analysis on Patient Satisfaction with Maternity Wards The sample is not described in detail but the authors suggest the measure can be used to assess satisfaction following different types of birth. Content and face validity were established through item generation, as items were created on the basis of a literature review, interviews with women who had recently given birth, and the clinical opinion of investigators. However, the questionnaire was not pilot-tested. Construct validity was established by embedding three mood questions in the tool, and comparing satisfaction between women Sawyer et al. BMC Pregnancy and Childbirth 2013, 13:108 http://www.biomedcentral.com/1471-2393/13/108 with high and low mood scores. As predicted, those in the low mood group were less satisfied with care in comparison to those in the high mood group (p < .05). Construct validity is also supported by findings from two other studies. One used the LADSI to compare satisfaction with midwifery or doctor-led care [5]. As predicted, women were most satisfied with midwifery-led care. The other used a modified version of the LADSI, [25] and found that satisfaction scores were positively associated with health of mother and baby, perceived control and expectations. Complications with labour and birth were associated with lower satisfaction. Care provided by midwives rather than doctors was also associated with higher satisfaction [25]. The LADSI appears to have face validity and content validity, and there is some evidence of construct validity. Although the questions are phrased so that they can be answered by men, psychometric assessment was not conducted for men. Internal reliability of the measure is questionable. Scores were reasonably stable over the two time points (r = 0.64) [15] but Cro … Get a 10 % discount on an order above $ 100 Use the following coupon code : NURSING10

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