Quality of Healthcare Services toward Hemodialysis Unit in Al Diwaniyha Government
Irfan Abdulzahra Al-Khazaali1, Dergham M. Hameed2, Ali J. Eidan3
1Ministry of health, Al Diwaniyah Direction, Al Diwaniyah Teaching Hospital, Msc nursing student in Al- Kufa University in Iraq, E-mail: [email protected]
2Professor. PhD, Dean of nursing college in Al Muthnna University in Iraq
3Department of Basic Medical Science, Faculty of Nursing, University of Kufa, Najaf, Iraq E-mail: [email protected]
Abstract
Chronic kidney disease is the most common devastating injury that represents a major societal health problem worldwide that may lead to an enormous long-term burden on the physical, psychological, social and economic condition of an individual, their family and health services. To assess patient satisfaction with the quality of health care services provided at Al Diwaniyah Teaching Hospital at Zahra Dialysis Center, A descriptive (quantitative) study was conducted in Diwaniyah General / Dialysis Unit from (15September 2020) to (22May 2021). The study aims to assess the quality of healthcare services provided to dialysis patients. A non-probability sample (target sample) of (100) patients who were admitted to Diwaniyah General Hospital/Dialysis Unit to receive treatment was included in the study sample. The data is collected using a questionnaire consisting of two parts: the first part consists of demographic data that contains (9) elements, and the second part consists of (25) items distributed into five areas of the quality of health care services, (7)) the tangible elements in the field, (5) Elements in reliability domain, (4) elements of field of response, (5) elements of empathy, and finally (4) elements of field of assurance. To determine the validity of the study, (19) experts were selected to review the questionnaire, and the validity of the questionnaire was determined through the experimental study to know the internal consistency of the elements using a half-split, which is r = 0, 85. The data were collected in a direct interview method with patients on hemodialysis. The researcher analyzed the data through the use of descriptive statistical procedures. The results of the current study indicate partial satisfaction by patients with the quality of health care services provided in the dialysis unit, especially in terms of reliability, responsiveness and sympathy with the quality of health care services, while the patients are at a high degree of partial satisfaction. Moreover, the study concluded that half of the patients are satisfied with the quality of healthcare services provided in the Dialysis Unit. The study recommends the following: - Continuously assessing the quality of health care services in the dialysis unit in order to implement quality improvement and/or quality assurance in this unit. Health education programs and infection control training courses should be implemented for nurses to increase and improve their capabilities in managing a patient under dialysis.
Keywords: Quality of Healthcare Services, Hemodialysis, Domains, patient satisfactions
Introduction
Chronic disease has become a health problem and a major cause of morbidity and mortality.
It is reported that 80% of the Global Status Report of Non-Communicable Diseases (2010) of chronic disease deaths worldwide occur in low and middle income countries. End-stage kidney disease (ESRD) is a major threat worldwide, it is a chronic disease, and it increases morbidity and mortality rates, increases the burden in the health care system and reduces the quality of life (QOL). According to the World Health Organization, Global Burden of Disease Project, nephrology and urology contribute to the global burden with approximately 850,000 deaths each year and disability-adjusted life years(1-2). End-stage renal disease (ESRD) may occur as complication of other disease such as: diabetes mellitus, hypertension, renal-vascular disorder, immunologic disorder, lupus erythematous, tuberculosis urinary tract obstruction and obesity, may extended to prostate and urethral disorder, congenital anomalies of kidneys. End-stage renal disease is the end of the stage of chronic kidney disease, as the kidneys do not work sufficiently and well to meet the needs of daily life. Therefore, at this stage to ensure survival, renal replacement therapy is required, and hemodialysis (HD) treatment is considered essential and plays an important role that is most commonly used in increasing patients' lifespan, when comparing HD patients with healthy individuals from the
general population as well as kidney transplant patients, a significantly weak level was observed(3, 4). Hemodialysis is recommended after symptoms and complication of chronic renal disease development, the patients face multi-dimensional troubles such as, physiological losses and lifestyle alterations. When hemodialysis started it's affected the patients and his family life as: role change, difficulty of working and holding his job, hemodialysis needs transportation, maintains medications and requires frequent visits to the physician which unfortunate, affect the patient's economic status. Furthermore, chronically ill that can create low self-esteem, less controlling of the disease(5-6). The quality of the nursing care provided is a great indicator of the nurses' involvement in the preparation of the care evaluation. In their qualitative study, Schweppur reported that patients feel more comfortable with nurses in close proximity to modern facilities and environment. This is an indication that the human role of patients conflicts with their rare need for technical nursing and modern specialized facilities(7-9). Sometimes, nursing care lacks the safety and sufficiency of necessary patients. Therefore, we must, at the present time, as researchers, set a goal for future studies to explain the structure of the nursing care plan and put the nursing care dimensions into standard care. This, indeed, requires identifying the causes that prevent nursing care, as the work of many nurses in the dialysis unit makes them exhausted due to factors such as lack of resources and heavy workload(10-11). In spite of the fact that nephrology medical caretakers play an imperative part in deciding the ampleness and quality of care in hemodialysis patients, few ponders in Asia have inspected the quality of nursing care. In the interim, ampleness of the given care is surveyed by quantitative measures instead of subjective ones, while qualitative thinks about give the finest device for understanding human encounters and is more fitting for evaluating the encounters and sees of a gather of individuals on a particular subject. Subjective investigate is based on the theory that there's an energetic truth and proposes a point of view for looking and understanding human components that cannot be measured through quantitative inquire about strategies, subsequently, considering the significance of the quality of nursing care and understanding profound encounters of medical caretakers, as well as the writing audit that shown few ponders on encounters of hemodialysis patients(12).
Materials and Methods
A Non experimental descriptive design study was conducted was adopted in the current study to assess the quality of healthcare services provided to hemodialysis patients. The research was conducted in Al-Diwaniyah/Diwaniyah Health Directorate / Al-Diwaniyah General Hospital/Al-Zahra Dialysis Center and the study began from 2021. A probabilistic (targeted) sampling technique was used which consisted of (100) patients who were admitted to Diwaniyah General Hospital. / Hemodialysis center to receive treatment. The evaluation tool was approved and developed by the researcher to assess the quality of health care services provided to dialysis patients. The last indicator for the study tool consists of (2) two parts:
Part 1: Socio-demographic characteristics: (9) Patient data elements (residence, gender, age, marital status, educational level, occupational status, socio-economic status, duration of dialysis during the week.
Part 2: Clinical history. This section includes (heart disease, diabetes, anemia, high blood pressure, respiratory problems, kidney transplantation, and others.
Service Quality Scale, which consists of a five-dimensional model that includes tangibility, reliability, responsiveness, empathy, and warranty. Quality of service as suggested by Parasuraman et al. (1988) (11). A five-point Likert scale was used in this study, and it was confirmed with strong approval, agree, unsure, disagree, and strongly disagree with scores of 5, 4, 3, 2, and 1 respectively on a Likert scale of 1-5. Tangible: This field was measured
through (7) elements that represent the appearance of physical facilities, equipment, personnel, and communications. Reliability: means the ability to perform service accurately and reliably. It is measured in (5) seasons, criteria for evaluating this dimension, accuracy of records approved by the hospital administration, accuracy of appointments in medical procedures. Providing the service on time in a reliable, accurate, consistent and reliable time without errors, and developing solutions to the patient's problems, this leads to giving him a feeling of confidence and the medical service providers. Response: A desire to help clients and provide services. It is measured with (4) elements. Empathy: Is mean's care and individual attention to clients measured by item (5). Affirmation: It means the employees' knowledge, kindness, and ability to convey trust and confidence. It was measured in (4) classes. Data were collected from (January 21th, 2021 to March 27th, 2021). Data were collected through the application of the specified questionnaire and through a structured interview with the people who were interviewed during the dialysis process. Each subject was interviewed in the same manner using a similar questionnaire for the study sample individuals in the dialysis unit. Participants are required to answer the questionnaire within (20-25) minutes, as the data were analyzed through the use of the statistical analysis system and the application of Excel program. Analyzing data by applying descriptive statistical methods, it includes analysis of metadata (frequencies, percentages, average scores), cut-off point (0.66), statistic (pie charts), and Pearson correlation coefficients (reliability).
Results
Table (1): Statistical analysis of the demographic data of 100 samples
Variables Category Frequency
(count)
Percentage [%]
Resident Urban 54 54.0
Rural 46 46.0
Total 100 100.0
Gender Female 38 38.0
Male 62 62.0
Total 100 100.0
Age {Years}
Mean= 51.31 STD= 14.20
≤ 34 12 12.0
35-44 22 22.0
45-54 21 21.0
55-64 23 23.0
≥ 65 22 22.0
Total 100 100.0
Marital Status
Single 5 5.0
Married 82 82.0
Widowed 9 9.0
Divorced 2 2.0
Separated 2 2.0
Total 100 100.0
Educational level
Illiterate 21 21.0
Able to read and write 17 17.0
Primary school graduated 27 27.0
Intermediate school graduated
16 16.0
Preliminary school graduated
6 6.0
Institutes 10 10.0
College 3 3.0
Total 100 100.0
Occupational Status
Employee 15 15.0
Free business 11 11.0
Retired 29 29.0
Housewife 29 29.0
Jobless 16 16.0
Total 100 100.0 Monthly
Income
Poor 76 76.0
Moderate 19 19.0
Good 5 5.0
Total 100 100.0
Socio- Economic Status
Sufficient 27 27.0
Sufficient to some extent 37 37.0
Insufficient 36 36.0
Total 100 100.0
Hemodialysis duration per week
2 15 15.0
3 66 66.0
4 19 19.0
Total 100 100.0
Table (2) Statistical analysis of clinical history of 100 samples
Disease Frequency Percentage
[%]
Heart disease 8 8.0
DM 13 13.0
Anemia 16 16.0
Hypertension 11 11.0
Respiratory
problems 10 10.0
Kidney
transplantation 12 12.0
Others 4 4.0
Combined two or more diseases from above
26 26.0
Total 100 100.0
Table (3): Overall satisfaction assessment of quality of health care services based on all examined domains
Domain Category Frequency Percentage
[%]
All examined domains
Satisfied 0 0.0
Partially satisfied 78 78.0
Unsatisfied 22 22.0
Total 100 100.0
Figure (1): Overall satisfaction assessment of quality of health care services based on all examined domains
Discussion
Part-I: Results discussion and comparisons based on the socio-demographic characteristics
The results of the demographic questionnaire of the 100 patients who are rested in the hemodialysis unit are reported in Table 1 and discussed herein and compared to available studies. The results show that majority of patients who visited the hemodialysis unit were male (62%) with ages ranging from 55-64 years and above: 23% patients with ages (55-64) years and 22% patients with ages ≥65 year. Also, the table indicates that the majority is married (82%) and most of them graduated with primary school degree (27%). Additionally, the results show that majority of the patients are with low incomes (poor: 76%) and they are retired (29%) or jobless (16%) with socio-economic status (37%) that is sufficient to some extent. The results show that most of patients come to hemodialysis unit 3 days a week (66%). The reported results are consistent with a study performed by Mansour, K & Shnishil, A (2013) and Sahib. I. et al, (2019) they authors of the mentioned study have examined the patients’ satisfaction toward nursing care at hemodialysis units in Bagdad hospitals. The authors collected data from 150 patients and reported the data. They found out that majority of patients was male (82 out of 150) that lead to 54.70% which is close to the finding in this study. Also, the paper indicated that the highest percentage of the patients aged with (51-60) years old with 24.66%, while our results were with 22% of age range from 55 to 64 years old(13. 14)., which is still in agreement with the literature. Moreover, we have found that majority of the patients who visited the hemodialysis unit in Al-Dewaniyah are married with primary school degree, which is make it approximately in consistent with the study conducted by Shnishil, A. & Mansour, K. (2013). The authors showed that 67.30% of the patient were married and among the patients 37.00% holding a primary degree(13). Additionally, the authors reported that 20.00% of the patients were retired and 25.00% of them were unemployed with barely sufficient socio-economic status, while in our study we have gotten 29.00% retired and 16.00% jobless. Orlic, L. et al. (2004) in their study showed that the majority of collected samples were classified as retired. The comparison of the results is well matched between the conducted study and the results from literature when we consider the variation in the samples (i.e., standard deviation) and the number of collected samples(15). Shnishil A & Mansour, K (2013) and Sahib I et. al, (2019) reported that majority of patients performed the hemodialysis process 2 times a week (95.30%) and (75.00%), respectively, whereas in our study, we have evaluated the hemodialysis duration based on weekly visit and we found out that most of patients come to hemodialysis unit 3 days a week (66%), which make it in disagreement with literature. From my perspective, the duration can be different based on the available equipment, staff and the crowds in the unit; all these factors can affect
the hemodialysis duration per week (13. 16). In this field there are several studies ended up with the same conclusion of the results discussed above. For instance, Al-Jumaih et al. (2011) reported the results of 100 samples and indicated that 64.40 % were male and 61.10% of age more than 40 years old. They also showed that many of patients were married (62.60%) and the patients were having a degree below the secondary school (61.00%). Same conclusions can be found in Karkar, A. (2015). All these studies and the discussed results make us confident about the obtained results(17). Table 1indicates that more than half of the patients are from urban residents (54.00%) which agrees with study conducted by Hameed AF.
(2006). In general, the hemodialysis unit located in Al-Dewaniyah hospital which it is in the central part of Al-Dewaniyah city and it is expected that the majority of patients are from urban residency. In most of the rural areas, we have hospitals and expected patients from there can receive the treatment; as a result, the number of patients from rural areas expected to be less(18). Finally, as part of demographic analysis, we have collected the clinical history of each patient which reported in Table 2. Itappears that many of patients have more than single diseases as shown in the table, namely: “combined two or more diseases” with 26%
from overall reported diseases. If we disregarded the combination of diseases, we can induce that the anemia has the highest percentage (16.00%) among other diseases. Based on the conducted research by Ponce, et al. (2019) in Mexico, they reported that majority of patients have identified with hypertension; in our study we obtained 11.00% of patient with hypertension which is not the highest. In my opinion, this difference can be related to the environment where the studies were conducted. In Iraq, most people suffer from several diseases and it is expected that the majority will have mix diseases as was shown previously.
However, in foreign countries such as Mexico, the environment is different and can leads to less stress nd less diseases (i.e., beautiful landscape and various sports habits)(19). Overall, as researcher, the authors believe that the findings of this study are consistent with published studies and with highly confidence this study can be a good reference to examine and develop the hemodialysis unit in Al-Dewaniyah city based on the demographic data.
Part-II: Results discussion of overall assessment of the health care services quality based on five domains over all items in all domains
This section describes the overall satisfaction of the patients about each domain. For all domains, we observed a very low percentage of satisfaction about the healthcare services provided in the hemodialysis unit. The results show that the “partially satisfied” is the highest for all domains, as explained in Table 3 and represented graphically in Figure 1.Based on our opinion, the partially satisfied choice is the right answer for all domains. Even though the location of the hemodialysis unit is appropriate and easily accessible for patients live in urban areas, the equipment, patients’ privacy, provided services and time management still not perfect and need a lot of improvements. For instance, the unit has a very few waiting rooms, and only one clinical room with scarcity in supplies that are necessary. As a result, I totally agree with the patients and support their choice (partially satisfied). Also, since the recent development and new equipment can easily buy, the governmental hospitals need to be in competition with private hospitals to get a full satisfactory of the patients. The findings of this study are in agreement with study performed by Lim, P. C., & Tang, N. K. (2000). The authors examined the patients’ expectations based on six domains, namely: tangibility, reliability, responsiveness, assurance, empathy and accessibility and affordability. A data collected from 252 patients of Singapore hospitals and the results show that those patients were partially satisfied with the provided services. The authors recommended improvements are required in all six dimensions(20). Based on the results, majority of patients were partially satisfied, then a reasonable percentage of patients were totally unsatisfied with the healthcare quality. Asaad, B. & Mahmoud, H. (2016) evaluated the patients’ satisfaction about health
quality in Lattakia, Jableh city from tangibility, reliability, responsiveness, empathy, credibility and safety dimensions. They concluded that health services centers in Jableh city lack quality, depending on the dimensions of quality health services. Thus, the patients’
satisfaction about the quality of healthcare is varied between unsatisfied and partially satisfied(21).
Conclusions
The main highlights of this study can be summarized in the followings:
• The study examines and analyzes (9) items to explore the patient demographical data, namely (residence, gender, age, marital status, educational level, occupational status, socio- economic status and the duration of hemodialysis during the week).
• Five domains are reported to study the patients satisfactory about the provided health services in the hemodialysis unit. It appears that patients are not satisfied about the quality of services in the hemodialysis unit for each individual item listed within each domain.
• Overall, majority of patients were partially satisfied with the level of healthcare services toward the following areas of healthcare services: (tangibility, reliability, responsiveness, empathy and assurance). The study also indicates that patients are more likely to be unsatisfied compare to satisfied category with all areas of healthcare quality.
Recommendations
• Train the staff (workers, nurse, managers) in the hemodialysis unit about how to deal in polite way with the patients and provide them with support and empathy.
• Provide the basic requirements (medicines, equipment, electricity, water, etc.) to facilitate the work of the medical and nursing staff and meet the needs of patients.
• Renewal of dialysis machines and updating them constantly by ministry of health and sending a represented to monitor the circumstances in the unit.
• Make a good environment for the patients in the unit, such us providing a good light, good lookout from outside, garden for walking and that will make the patients feel safe.
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