Assessment of Hospitalised Patient Satisfaction with Nursing Care in the Gynaecology and

: Satisfaction with nursing care is believed to be an indicator of the quality of the health setting, for this reason, many stakeholders and managers focus on measuring patients’ satisfaction to gather crucial information that could improve nursing service quality. The purpose of this study was to assess patients’ satisfaction with nursing care in the gynaecology and obstetrics department at Benghazi Medical Center (BMC) in Libya. Method: This study utilized a cross-sectional survey design. The survey was conducted from April to May 2022. Participants: - The population of the study consisted of adult patients who agreed to participate in the research and met the inclusion criteria, A convenient sampling method was applied in this study (n=300). Instrument: The data were collected through patient satisfaction with the nursing care quality questionnaire (PSNCQQ). The first section collected general information and demographic data; the second section consisted of a questionnaire related to patient satisfaction with nursing care. The scale included additional questions designed to assess satisfaction with the overall quality of care and treatment received during hospitalization, the overall quality of nursing care, and the likelihood that the patient would recommend the hospital to relatives and friends. The findings: The patients rated their satisfaction with nursing care as being at a low level of satisfaction. Moreover, patients reported less satisfaction with the overall quality of care and services received during their hospital stay and reported that they would not recommend this hospital to their families and friends. Recommendation: Periodic assessments to measure patients’ satisfaction levels with nursing care in different units and locations, and with a larger sample, could help healthcare facilities to guarantee the provision of high-quality patient care. - The results of the evaluation should be used to develop potential new strategies to improve the level of nursing services in the hospital.


Background
Nurses play a vital role in health care for both the individual and the institution (1) . When it comes to patient satisfaction, it is principally the role of nurses because they are directly involved in patient care, from admittance to discharge (ibid.). Satisfaction with nursing care is believed to be an indicator of the quality of the health setting (2,3) ,for this reason, many stakeholders and managers focus on measuring patients' satisfaction to gather crucial information that could improve nursing service quality (4) . Measuring patient satisfaction is important not only to improve the quality of service, but also, as indicated in the literature, for nurses to identify areas of failure and planning so they can implement necessary training (4,5,6) .
The service provided by the hospital can be assessed by the level of patients' satisfaction with nursing care. Nursing staff spend the most time with patients compared to other health professionals; therefore, they have a significant impact on the overall level of patient satisfaction (7) .A number of studies in Western countries have found that patient satisfaction or dissatisfaction may be affected by various factors, including social status, age, educational level, cultural background, previous hospital experiences, type of department, level of care and respect from nurses, and continuous availability of nurses, (5,8,9,10.11.12,13) . as well as patients' physical and psychosocial well-being (5,8,9,10) . Consequently, evaluating patient satisfaction with nursing care is complicated, specifically in obstetrics and gynaecologic departments, because the job requires a lot of empathy and compassion; it is not just about giving patients the right medications or performing a procedure correctly (5) . Patient satisfaction with nursing care and satisfaction with hospital services are positively correlated; however, health policymakers in developing countries seem to ignore this important fact when making decisions about the availability of health services (14,15) . Patient satisfaction with nurses in hospitals is well measured in developed countries; however, insufficient patient satisfaction studies have been conducted specifically in the medical wards in Libyan hospitals. Therefore, this study aimed to assess patients' satisfaction with nursing care in the gynaecology and obstetrics department at Benghazi Medical Center (BMC) in Libya.

Materials and methods
2.1 Design of study :-this study utilised a cross-sectional survey design to examine patients' satisfaction with nursing care in the gynaecology and obstetrics department at BMC, Libya. 2.2 Participants:-A convenient sampling method was applied in this study. The population of the study consisted of adult patients who agreed to participate in the research and met the following inclusion criteria: had stayed in the gynaecology and obstetrics department for at least 12 hours; aged 18 and above; admitted to the gynaecology and obstetrics department; patients who were receiving nursing care; "able to speak either Arabic or English; and not experiencing severe pain. Exclusion criteria included patients who were: unconscious; did not respond to verbal stimuli; blind, deaf, or did not respond or communicate; or experiencing mental illness or providing unreliable responses. The study sample of patients (n = 300) represented the sample of this study. The survey was conducted from April to May 2022. 2.3 Data collection procedure:-2.3.1 Instrument: The data were collected through the patient satisfaction with nursing care quality questionnaire (PSNCQQ). This questionnaire was derived from the patient judgement of hospital quality (PJHQ) questionnaire designed to measure satisfaction with the overall quality of care during the hospital stay, overall quality of nursing care, and intention to recommend the hospital to family and friends (16) .The questionnaire utilised a five-point rating scale-excellent, very good, good, fair, and poor. The structured questionnaire consisted of two sections. The first section collected general information and demographic data, including age, marital status, date of admission and number of previous admissions, admission path way , and diagnosis. The second section consisted of a questionnaire related to patient satisfaction with nursing care (ibid.). The scale included additional questions designed to assess satisfaction with the overall quality of care and treatment received during hospitalisation, the overall quality of nursing care, thoughts on overall health, and the likelihood that the patient would recommend the hospital to relatives and friends (16) . A pilot study was conducted using 10 subjects (calculated based on 10 percent of the total number of subjects) to determine the reliability of the questionnaire. The Cronbach's alpha reliability estimates for the PSNCQQ were excellent (.97). Total item correlations were high, ranging from 0.58 to 0.86. The translated and original versions of the PSNCQQ were compared and found to be highly similar in meaning. 2.4 Methods of data analysis: Data were analysed using the statistical package for the social sciences program (SPSS, version 23(. The analyses were conducted on the basis of aim, and the data were presented using descriptive statistics. Data were summarised into tables and bar graphs percentages. 2.5 Ethical considerations: The researcher sought approval for the study from the BMC. Information about the study was explained to the participants, including the procedures and potential benefits of the study. The patients were informed of their right to refuse or decline participation in the study at any time and that refusing to participate in the study would not negatively affect them. Participants' confidentiality of information was assured by excluding names and identifiers from the questionnaire. Informed verbal consent was obtained from all respondents prior to the study, and privacy was respected for all patients.

Results:-
3.1 :-Demographic Characteristics:- The majority of the respondents were between the ages of 19-28 and 29-38 years, 47.3% and 45% respectively. Regarding times were the patient hospitalized in the past two years; 34% of the respondents had three times hospital admissions; followed by 27% and 26.3% of the respondents who were experiencing second and first-time admission to a hospital respectively. Approximately 42% of the respondents were admitted through the Emergency department; followed by 40.3% of them admitted through unit direct. The majority of the respondents (58.3%) stayed in the hospital's room with more than one other patient; while 33.7% of them stayed in the hospital's room with one other patient. According to Table (2) above Patients' overall satisfaction with the nursing care in the gynaecology and obstetrics department at Benghazi medical center (BMC) was (Mean=2.5, SD =1.5). This indicates that the overall level of patient satisfaction was at a low level. However, The respondents reported that the five highest mean ratings towards their satisfaction were 'How well nurses and explained how to prepare for tests and operations' (Mean=3.2; SD=1.6), followed by 'How well things were done, like giving medicine and handling IVs' (Mean=3.1; SD=1.5), then 'Willingness of nurses to answer your questions' (Mean=3.0; SD=1.6), 'How well nurses communicated with patients families and doctors' (Mean=2.9; SD=1.7), as well as 'How much they were allowed to help in your care' (Mean=2.7; SD=1.7). These ratings indicate that the level of patient satisfaction was at a moderate level. Whereas, items with the five lowest mean ratings were 'Willingness of the nurses to be flexible in meeting your needs' (Mean=2.4; SD=1.3); followed by 'How much nurses ask you what you think is important and give you needs' (Mean=2.3; SD=1.6), next 'How well the nurses kept them informed about your condition and needs' (Mean=2.1; SD=1.5), then 'How clearly and completely the nurses told you what to do and what to expect when you left the hospital' had (Mean=1.8; SD=1.2), and 'nurses efforts to provide for your needs after you left the hospital' (Mean=1.6; SD=1.0). Besides, these ratings indicate that the level of patient satisfaction was at a low level.

Figure (1): Overall perceptions about patient satisfaction
According to figure (1), findings from patients in the gynaecology and obstetrics department at Benghazi medical center (BMC) showed that the whole was dissatisfied with the quality of care and services (M=2.0; SD=1.1) while, the participants reported that the mean ratings towards their satisfaction were quality of nursing care in hospital (Mean=2.1; SD=1.0),followed by 'recommend this hospital to my family and friends" (M=2.4; SD=1.5).these results above indicate that the level of patient's satisfaction was at a low level. Overall patient satisfaction means the score is in line with the earlier results of this study.

Discussion:-
In general, the findings from this study indicated that patients in the gynaecology and obstetrics department at Benghazi Medical Center (BMC) were dissatisfied with the overall quality of nursing care. These results were like previous studies, such as one conducted in the medical and surgical inpatient departments of the Main University Hospital in Alexandria, where 55.3% of hospitalized patients were unsatisfied with nursing care (16). Furthermore, a study conducted in Saudi Arabia (17) revealed that more than half of patients rated their satisfaction low.
In this study, the lowest levels of satisfaction, represented by PSNCQQ scores, were reported for the following items:- "Nurses efforts to provide for your needs after you left the hospital"  "How clearly and completely the nurses told you what to do and what to expect when you left the hospital"  "How well the nurses kept them informed about your condition and needs"  "How much nurses ask you what you think is important and give you needs" The results indicated that the most frequently missed types of care were comforting and talking with patients and teaching patients and family members how to manage care after discharge. Also, the nurses were less interested in explanations about their interventions and communication with patients. In other words, nurses did not meet patients' expectations.The level of satisfaction with nursing care was low compared with the findings of international studies (19,20) . regardless of whether the other studies were conducted in developed or developing countries with a similar culture (19) . This difference could be the result of several factors, such as the nurse's skills and manner of communication with patients and the patient's education and age (19) . Additionally, according to the literature, there are several explanations for the low level of patient satisfaction with nursing care, such as 1. the shortage of nurses in comparison to their duties and responsibilities and high number of patients, 2. individual characteristics and attributes of patients , 3. the physical environment and specialist care, 4. interpersonal manners and sociocultural aspects of patients' care, 5. the nurses' competencies and skills, 6. financial shortages and 7. nurses' satisfaction with their jobs ( 21) . Obstetric and gynaecologic nurses clearly provide care to vulnerable populations, and the most important concern when working with these groups is maintaining a positive attitude. The job requires a lot of empathy and compassion; it is not just about giving patients medications or performing a procedure correctly. Subsequently, the level of satisfaction among hospitalized patients in this unit is affected by the level of physical and psychological care of patients.
The findings of this study show that patients reported less satisfaction with the overall quality of care and services received during their hospital stay and reported that they would not recommend this hospital to their families and friends. An explanation for this result might be that the patients were not satisfied with the overall quality of nursing care. This result is consistent with a study in Libya (2020) that revealed the low quality of health services provided by the Benghazi Medical Center and deficiencies in the nursing services provided to the patients (22) . Similarly, this finding is consistent with a study in Brazil (23) . which found a correlation between nursing care quality and patient satisfaction.

Conclusion :-
Nursing care is considered one of the crucial factors that affect patient satisfaction with their hospital stay. It has become a commonly used indicator of how satisfied patients are with healthcare services. The findings of this study revealed that the perceived satisfaction level regarding the quality of nursing care was generally low. The patient's satisfaction with the nursing care they receive has a direct influence on their perception of the hospital's overall quality. Finally, the findings of this study present a framework for both managers and policymakers to seriously think about continuous quality improvements as an urgent area.

Recommendations
6.1 The first step toward improving patient satisfaction will be to identify where practices fall short of expectations. Therefore, the findings obtained from this evaluation should be taken into consideration when determining training requirements for nurses. 6.2 Measuring patient satisfaction with nursing care is not straightforward. Satisfaction is a complex concept that is influenced by factors including socio-demographic characteristics, physical and psychological status, attitudes toward and expectations of medical care structure, process, and outcome of care. Therefore, more studies need to be conducted on the effects of these factors on patient satisfaction. 6.3 Periodic assessments to measure patients' satisfaction levels with nursing care in different units and locations, and with a larger sample, could help healthcare facilities to guarantee the provision of highquality patient care. 6.4 In-service educational programs should be developed and implemented for all nurses who wish to raise their awareness of the attention to patient satisfaction. 6.5 The results of the evaluation should be used to develop potential new strategies to improve the level of nursing services in the hospital. 7. Limitations of the study: The findings of this study may not be generalisable due to the use of the convenience sampling method. The results may have been influenced by a potential non-response bias. Also the research is the cross-sectional design, which does not inform us about causation. Longitudinal analysis would better assess causality and identify potential unmeasured variables. The study is being conducted in a single public hospital in Benghazi therefore, future investigations should include more than one hospital in both the private and public sectors.

Conflict of Interest:
The authors declare that they have no conflict of interest.