Patient satisfaction with nursing after surgery due to cervical or lumbar discopathy

Background

The quality of nursing care is the focus of research across a wide range of medical specialties, in hospitals and primary care, and also across a range of various diseases. Issues related to nursing care for hospitalized chronic low back pain patients due to spinal disc disease have not previously been specifically examined in Poland.

About 90% of the population has low back pain and cervical pain at some point in time and 30% of these will develop leg pain or arm pain. The most common cause of sciatica or cervico-brachial neuralgia is lumbar or cervical disc prolapse causing nerve root compression. Most patients achieve good pain relief with conservative treatment and less than 20% require surgery. Surgical interventions have been found to restore function, decrease pain, and enhance quality of life in properly selected patients [1–4].

Chronic pain is associated with an array of health problems and nursing care of pain patients in a variety of clinical settings. Patients expect nurses not only to help in maintaining hygiene and meeting biological needs, but also to help eliminate patient pain. Patients emphasize that they expect the following from the nursing team: punctuality, responsibility, kindness, good manners, reliable information on the activities undertaken, mental preparation for surgery, and information about their condition [5]. The results of a study by Wasilewski [6] carried out in part at our Department of Neurosurgery, also indicate the very important psychosocial aspect of social support involved in nurturing the sick. Measures of the support nursing staff provide to patients are very important. Patients experiencing pain and anxiety as well as concern about their future health often lack a sense of security. Psychosocial care includes measures ensuring improvement in the patient’s mood, adaptation to a new social group (the patient’s relationship with the staff), contact with family and loved ones, and showing interest in the patient’s health problems, profession, and family. Respect for an individual’s personal dignity is fundamental. A study of patients hospitalized due to lumbar disc herniation also points out the ability to provide for religious and spiritual needs [7].

As stated by Lin [8], there are many issues to be considered when patient satisfaction is used as an outcome variable. Many factors influencing patient satisfaction were revealed in the previous studies. Findik et al. [9] emphasized that the evaluation of the association between the level of satisfaction with nursing care and patients’ characteristics is of particular importance since it would provide information useful for assessing the quality of nursing care, problem resolution, and the preparation of nursing care plans. For example, patient socio-demographic characteristics (e.g., sex, age, and marital status), physical and psychological health, and expectations of care may be reflected in satisfaction results [10,11]. Socioeconomic status, educational level, and income of patients are important factors that also affect satisfaction [10,11]. In addition to these personal characteristics, the hospital ward in which the patient is being treated and the duration of hospitalization are also important factors [14]. The dimensions of nursing care that influence in-patient satisfaction include the provision of clear information, the opportunity for patients to participate in their own plan of care, nurse availability, care that is competent with regards to interpersonal relations, nursing knowledge, and technical skills [15].

Furthermore, Crow et al. [13] identified 61 studies that examined the relationship between patients’ socio-economic and demographic characteristics and their reported satisfaction with health care. However, no firm conclusions were drawn about the relationship between reported satisfaction and patient gender. Alasad and Ahmad [16] found that females were more satisfied with care than males, whereas in a study of Findyk et al. [9], male patients were significantly more satisfied with the nursing care than female patients.

Considering other socio-demographic variables, differences were also found in age and education in relation to the level of satisfaction with care. Crow et al. [13] pointed out that older respondents were significantly more satisfied. Thi et al. [17] concluded that patient age is the most consistent characteristic that defines their satisfaction with the nursing care provided.

Some authors have confirmed relationships between patient satisfaction with health services and the health problem for which the patient is being treated, as well as the clinical results of treatment [12,14,18–21]. Other studies [22] have not shown any impact of patient satisfaction survey results on the improvement of healthcare delivery. To date, previous studies have failed to provide a full description of the interrelations between patient satisfaction with nursing and clinical, patient-related data, and are therefore unclear and inconclusive. We believe this issue needs further examination, specifically in regards to patients after surgical treatment for discopathy and degenerative spine disease in the cervical or lumbar spine. Furthermore, the design of the study should include evaluation of detailed patient clinical data, not analyzed in depth in the aforesaid patient samples, such as spine overload and neurological symptoms before treatment, number of discopathy levels, changes of signal intensity in spinal cord in MRI, sagittal dimension of vertebral canal on the discopathy level, Modic classification, smoking, and opioid use.

As researchers recognize, it is impossible to include all variables determining patient satisfaction with nursing in the study. Therefore, the specific objectives of the present cross-sectional study are: (1) to examine the level of postoperative satisfaction with nursing in patients with cervical or lumbar discopathy, (2) to analyze the differences between postoperative satisfaction with nursing in patients with cervical or lumbar discopathy, and (3) to determine whether selective preoperative and postoperative patient characteristics, as well as socio-demographic factors, affect satisfaction with nursing.

Material and Methods

STUDY DESIGN:

The study included 104 consecutive patients who were treated surgically from 1^st June 2009 to 31^st September 2010 in the Department of Neurosurgery and Neurotraumatology of Poznan University of Medical Sciences, due to disc herniation in the cervical or lumbar spine. The design of this prospective, cross-sectional study was approved by the Bioethics Committee.

PROCEDURE:

The inclusion criteria were: low back pain or neck pain lasting preoperatively for more than 3 months; surgical treatment due to lumbar or cervical discopathy and degenerative spine disease; a minimum 12-month follow-up; and age 18–60 years. All patients underwent a magnetic resonance imaging (MRI) Scan. The exclusion criteria were: tumors, metastases, spinal trauma, neurological and psychological disorders resulting in communication difficulties, pregnancy, and previous spine surgery.

The diagnosis of lumbar or cervical disc herniation was based on preoperative symptoms, clinical examination, and detection during MRI examination. The degenerative changes in the lumbar spine were evaluated according to the Modic scale [23]. Conservative treatment was applied first in all cases. All physical examinations and surgical treatment were performed by the same neurosurgeon.

Patients who fulfilled the study criteria received detailed information on the aim of the study. Participants were assured of anonymity and that a refusal to participate in the study would not affect further treatment. Participants signed a consent form before completing the questionnaire.

At the minimum 12-month follow-up, patients were asked to fill in the Polish version of the Newcastle Satisfaction with Nursing Scale (NSNS-PL)[24]. A phone-call follow-up was performed by a nurse, DG, the first author of the study. Patients were given detailed information about the study in case they required explanation or clarification and they were assured that the information they provided would remain anonymous and confidential. Then, questionnaires were sent to patients and returned to the Clinic by mail. The data were collected according to the directions of the NSNS users’ manual.

DATA COLLECTION:

Preoperative data (socio-demographic, pain-related, and clinical data) were collected during hospitalization in the neurosurgical ward, and constituted the first part of the study. For the second part of the study, postoperative questionnaires about employment status, satisfaction with treatment outcome, and, in particular, satisfaction with nursing care, were mailed to patients. After surgery, the patients were asked to subjectively assess the result of the surgery, rating their satisfaction with the results of the treatment and if they would undergo the same treatment again if necessary (the possible answers were: definitely yes, rather yes, rather no, and definitely no),. Furthermore, they were asked if they had returned to work after treatment (the possible answers were yes and no).

Comorbidities and smoking status were assessed as well. In the group treated for cervical discopathy, comorbidities such as hypertension, diabetes, venous thrombosis, gastric ulcer and hyperthyroidism were reported. In the group treated for lumbar discopathy, comorbidities such as hypertension, diabetes, asthma, hypothyroidism, glaucoma, coronary heart disease and arrhythmia were reported. Patients treated operatively due to lumbar (n=63) or cervical (n=41) discopathy and degenerative spine disease were asked to fill in both the preoperative (first part of the study) and postoperative (second part of the study) assessment packets.

OUTCOME MEASURE:

Newcastle Satisfaction with Nursing Scale. The NSNS, developed by Thomas et al. [15], measures patients’ experiences of and satisfaction with nursing. A structured, self-completion questionnaire was developed by asking patients, through individual and focus group interviews, what they perceived was good or poor quality nursing. The major issues that emerged were related to the availability and attentiveness of nurses, the degree of individual treatment offered to patients, and the provision of reassurance and information. Points mentioned less frequently included the professionalism of the nurses, how knowledgeable they were, and the ward organization environment. The scales are incorporated into a self-completion questionnaire, which consists of 3 sections: (1) the Experiences of Nursing Care Subscale, (2) the Satisfaction with Nursing Care Subscale, and (3) a section providing demographic information [15,25].

Experiences of Nursing Care Subscale (ENCS): a series of 26 statements on aspects of nursing are presented and respondents are asked to indicate how true each is of their own experience, using a 7-point Likert scale (1 disagree completely, 2 disagree a lot, 3 disagree a little, 4 neither agree nor disagree, 5 agree a little, 6 agree a lot, and 7 agree completely). The sum of the responses across all items is transformed to yield an overall ‘experience score’, with a potential range of 0–100, where 100 represents the best possible experience.

Satisfaction with Nursing Care Subscale (SNCS): 19 items are scored on a 5-point Likert scale (1 not at all satisfied, 2 barely satisfied, 3 quite satisfied, 4 very satisfied, and 5 completely satisfied). Summed total scores were transformed to yield an overall ‘satisfaction score’ of 0–100, where 100 denotes complete satisfaction/highest level of satisfaction with all aspects of nursing care [15].

Demographic information section, the final section, elicits information about the patient and details of the hospital stay. This section also includes 2 seven-point response scales about patients’ overall evaluation of nursing care during their recent stay in the ward and their evaluation of the hospital stay.

STATISTICAL ANALYSIS:

Descriptive statistics were used to summarize the demographic and clinical characteristics of the patients. We analyzed means, minimal and maximal values, and standard deviations (SDs). In the quality field, we supplied the number of units for specific categories of a given characteristic and their relative percentage values. To verify the relation between quantitative features or features expressed on ordinal scale, we used Spearman’s rank correlation coefficient (Spearman’s rho – rS). The Mann-Whitney test or the Kruskal-Wallis test was used to determine dependency between quantitative and qualitative characteristics. The Mann-Whitney U test was used to compare 2 groups in respect to certain quantitative features or features expressed on the ordinal scale as well.

We used logistic regression analysis to define the degree to which patient characteristics affect NSNS scores in both study samples. The satisfaction with nursing predictors were calculated with a stepwise regression analysis, in which the socio-demographic variables were entered in the first step. Preoperative clinical pain characteristics were entered in the second step, whereas postoperative clinical pain characteristics, conviction about the same treatment, and possibility to return to work were entered in the third step. Based on the lower and upper quartile distribution, the results of the NSNS were split into 2 categories: a “ very good result” (from 75 to 100 points) and “lack of a very good result” (from 30.26 to 74.99 points). The critical p value was set at 0.05. Test results with a greater value than this were deemed to be statistically irrelevant. Statistical analysis was carried out using the Statistica program.

Results

PATIENTS TREATED FOR CERVICAL DISCOPATHY AND DEGENERATIVE SPINE DISEASE:

Of the patients treated for cervical discopathy, 48.8% were female (20 patients) and 51.2% (21 participants) were male. The average age was 49.5 years (SD 8.6), range 30–67. The average duration of preoperative pain in the cervical spinal region was 46.4 months (SD 66.9), range 3–360. At the follow-up, patients were available at a mean of 22.2 months (SD 4.0) after surgery (range 15–28 months); 43.9% of patients returned to work after treatment and 93% of patients would undergo the same treatment again if necessary. For detailed socio-demographic and clinical characteristic of both study groups, see Tables 1 and 2.

PATIENTS TREATED FOR LUMBAR DISCOPATHY AND DEGENERATIVE SPINE DISEASE:

Females made up 34.1% of study participants (15 patients) and males constituted 65.9% (29 participants). The average age was 42.83 years (SD 11.4), range 23–62. The average duration of preoperative pain in the lumbo-sacral spinal region was 35.7 months (SD 43.7), range 3–180. At follow-up, patients were available at a mean of 23 months (SD 2.47) after surgery (range 16–27 months); 54.5% of patients returned to work after treatment and 80% would undergo the same treatment again if necessary.

Patients with cervical and lumbar discopathy differed in regards to age (p=0.013), length of hospital stay (p=0.036), number of discopathy levels (p=0.029), and return to work after surgical treatment (p=0.030) only.

DESCRIPTIVE STATISTICS OF THE NSNS:

Table 3 presents the score distribution of the NSNS in both analyzed subgroups. In the group of patients with cervical discopathy, the average ENCS score was 82.0 (SD 15.1) and the average SNCS score was 75.6 (SD 18.1). The patient evaluation of nursing average was 5.9 (SD 0.8) and the average evaluation of their hospital stay was 5.7 (SD 1.0). In patients with lumbar discopathy, the average ENCS score was 79.0 (SD 13.5) and the average SNCS score was 74.4 (SD 16.8). The average of patient evaluations of nursing was 5.8 (SD 0.5) and the average evaluation of their hospital stay was 5.7 (SD 0.6).

The 2 study groups did not differ in regards to NSNS subscales, patients’ overall evaluations of nursing care during their recent stay in the ward, and evaluations of hospital stay (for details, see Table 3).

CORRELATIONS BETWEEN NSNS AND PATIENT CHARACTERISTICS IN PATIENTS WITH CERVICAL DISCOPATHY:

When we examined the relationships between patient characteristics and patient satisfaction (ENCS and SNCS scores), we found that the ENCS and SNCS scores showed a correlation with age of patients (rS=0.31, p=0.045 and rS=0.33, p=0.034, respectively). Furthermore, the ENCS score was related to opioid use (p=0.019). Patients using opioids scored higher in the Experiences Subscale. The ENCS score was associated with changes of signal intensity in the spinal cord in MRI (p=0.002) as well. Patients whose MRI examination indicated changes of signal intensity in the spinal cord scored higher in the Experiences Subscale.

The satisfaction with treatment outcome was associated with ENCS and SNCS scores (rS=−.34, p=0.032 and rS=−0.42, p=0.006, respectively). Similarly, conviction about undergoing the same treatment again was related to the ENCS and SNCS scores (rS=−0.36, p=0.022 and rS=−0.44, p=0.004, respectively). Satisfaction with treatment outcome was associated with patient’s overall evaluation of nursing care and evaluation of hospital stay (rS=−0.39, p=0.013 and rS=−0.51, p=0.001). Similarly, conviction about undergoing the same treatment again was associated with the patient’s overall evaluation of nursing care and evaluation of hospital stay (rS=−0.39, p=0.012 and rS=−0.49, p=0.001, respectively) (Table 4).

Strong associations between the ENCS and SNCS scores were confirmed in this group of patients (rS=0.73, p<0.001) and patient overall evaluation of nursing was strongly associated with ENCS and SNCS scores (rS=0.62, p<0.001 and rS=0.80, p<0.001, respectively). Evaluation of hospital stay correlated to both ENCS and SNCS scores (rS=0.65, p<0.001 and rS=0.73, p<0.001, respectively) and patient overall evaluation of nursing (rS=0.64, p<0.001) (Table 4).

CORRELATIONS BETWEEN NSNS AND PATIENT CHARACTERISTICS IN PATIENTS WITH LUMBAR DISCOPATHY:

A relation between the ENCS score and smoking emerged (p=0.046) (patients addicted to smoking scored higher in the ENCS Subscale). Patient’s overall evaluation of nursing care was associated with gender (p=0.030) (women tended to be more satisfied with nursing care) and opioid use (p=0.050) (patients using opioids tended to be less satisfied with nursing care). Furthermore, patients’ evaluation of their hospital stay correlated with the duration of pain symptoms before surgery (rS=−0.38, p=0.012) and spine overload before treatment (p=0.023) (patients who reported spine overload gave a lower evaluation of hospital stay).

Evaluation of hospital stay was associated with satisfaction with treatment outcome and conviction about undergoing the same treatment again (rS=−0.53, p<0.001 and rS=−0.37, p=0.013, respectively). Patient overall evaluation of nursing correlated to ENCS, SNCS, and evaluation of hospital stay scores (rS=0.37, p<0.012; rS=0.49; p=0.001;and rS=0.77, p<0.001, respectively). Evaluation of hospital stay correlated with ENCS and SNCS scores (rS=0.30, p=0.045 and rS=0.32, p=0.033, respectively). As in the cervical group, strong associations between ENCS and SNCS scores were confirmed in patients with lumbar discopathy (rS=0.73, p<0.001) (Table 4).

THE LOGISTIC REGRESSION ANALYSIS:

The logistic regression model derived from the first step of calculations revealed that in the group with cervical discopathy, only age had a statistically significant (p=0.012) influence on the probability of achieving a “good result” in the SNCS. An increase of 1 year in age increased the probability of a “good result” by 14%. In the group of patients with lumbar discopathy, only educational level had a statistically significant (p=0.038) influence on the probability of achieving a “good result” in the SNCS. An increase of 1 category of educational level decreased the probability of a “good result” by 60%. The logistic regression model for the third step of calculations revealed that conviction about undergoing the same treatment again has a statistically significant (p=0.012) influence on the probability of achieving a “good result” in the group with cervical discopathy in regards to the ENCS. An increase of 1 category within this variable increased the probability of a “good result” 4-fold. Similarly, conviction about undergoing the same treatment again has a statistically significant (p=0.014) influence on the probability of achieving a “good result” in the SNCS. An increase of 1 category within this variable increased the probability of a “good result” over 5-fold.

Discussion

STUDY LIMITATIONS:

Socio-demographic, clinical, and radiological characteristics of patients and their satisfaction with nursing care were evaluated in the present study; however, other characteristics affecting satisfaction (eg, nursing competence and clinical experience, patient psychological state, or level of experienced spinal pain) were not investigated. This makes it difficult to understand the effects of patient characteristics on satisfaction with nursing care and, therefore, might limit the generalizability of the study findings to the investigated features only. Another limitation of the present study was that patients filled out the NSNS on one occasion only (after surgery), which makes it difficult to determine whether postoperative satisfaction with nursing is associated with preoperative experiences and patients’ psychological state. Therefore, this issue warrants further research.

FUTURE RESEARCH IMPLICATIONS:

Considering future research implications, a detailed evaluation of each individual item of both the ENCS and the SNCS subscales would enable us to state hypotheses on which elements of nursing care should be corrected and improved in the investigated patient groups [36]. A detailed analysis of each individual question, especially those with the lowest scores, should be carried out in order to make appropriate changes and to improve nursing care. In addition, an analysis of the highest scores in regards to individual items would serve to indicate the nursing interventions that are evaluated the highest by the patient and which should be preserved and possibly enhanced.

Conclusions

Our study highlights the importance of assessing the association between patient characteristics and perception of quality of nursing care. It demonstrated that patients’ assessment of experience and satisfaction with nursing care was high in groups with cervical or lumbar discopathy, and that there was no significant difference between the patient groups in regards to satisfaction, experiences of nursing, and evaluation of hospital stay. Socio-demographic, medical history-related, and clinical data determined patient satisfaction with nursing. Furthermore, evaluation of hospital stay was associated with satisfaction with treatment outcome, conviction about undergoing the same treatment again, and experiences and satisfaction with nursing care in both analyzed patients subgroups. However, satisfaction with treatment outcome and conviction about undergoing the same treatment again affected experiences and satisfaction with nursing in the cervical group only.