Do we know what the patients think? A survey comparing the views of patients, staff and committee members

hr. J. Nurs. Bud.

Voi.4,

pp. 2W223,

Pergamoa hss,

1967. Printed in &eat &it&n

Do we Know what the Patients Think? A Surwy Comparing the Views of Patients, Sta$ and Committee Members WINIFRED

RAPHAEL

(Research Cotwltunt to the Royal College of Nursing and National Council of .hbr~es of tfw United Kincdcrn): 20 Clareville Grove, London, S. W. 7

Survey Method Used

Aim of enquiry THIS survey was planned to compare the views of patients about their conditions with the views of staff and of committee members in the same hospitals about conditions for patients. “Why are such surveys necessary?” it may be asked, “Surely people who are capable at their jobs know what the patients are thinking”. It is true that many of those staff members who are in direct contact with the patients do have good knowledge of most of their views, but there are other members of both staff and committees who seem unaware of matters that are of burning importance to their patients. Patients and their relatives often hesitate to volunteer even constructive criticism either because they feel strong gratitude to the hospital and they do not wish to appear grumblers or because they fear (probably without cause) that complaints might cause repercussions. Similarly some junior staff do not make suggestions for the improvement of conditions for patients in case this might be considered presumptuous by their seniors. Administrators and committee members, who have many important decisions to make on patients’ welfare, are at a particular disadvantage for they usually have little direct contact with patients and necessarily get most of their information second hand or by letters from an atypical group of patients-the most and the least satisfied. The result is that many good ideas go unheard and changes are not made that sometimes would cost little or nothing but would add enormously to the happiness of the patients. Even when suggestions A their relative priority. for each bed, but finances patients like best. 2 Which

for change are known it is frequently difficult to decide ward needs redecorating, new bathrooms and a radio only allow for one of these reforms. Which would the would the doctors and nurses like best? 209

210

WINIFRED

RAPHAEL

Survey method

To attempt to compare the views of patients and those who look after them at one type of hospital a survey was conducted by the author (under the auspices of the Royal College of Nursing and National Council of Nurses of the United Kingdom) in four general non-teaching hospitals. The survey method used was that of the unstructured individual interview: no questions were asked to suggest topics. People were invited to participate by means of a letter sent to them individually signed by a senior officer of their hospital. This asked them to help the hospital by saying what they found good about the conditions for patients and what they thought could be improved. They were assured that all suggestions would be considered but that no names would be mentioned in the report and that the person interviewing them had no connexion with the hospital. The interview with patients started by obtaining from them a few personal particulars. Then the interviewer said “I shall be most interested to hear what you think about the hospital, what you like about it here and what you think could be improved in any way”. A similar introduction was used with staff and committee members except that it was emphasized that questions referred to conditions for patients and not for themselves. Most people launched quite happily into an account of their views, favourable and unfavourable; indeed many had prepared lists of points to raise. Others required more encouragement. They would just say, “It is very nice here” or “I will be thankful to get out of the place” and these would be asked “What makes you feel that?” but care was taken never to suggest topics. At the end of each interview two questions were asked. The first was, “What is the most important thing to change here ? Of all the suggestions you have made which would you most like to be accepted from the patients’ point of view?” Of those interviewed 72 per cent were able to choose their most important suggestion. Many of the rest had only made favourable comments or found it difficult to pick out one suggestion as more important than another. For the second question a card was shown on which was typed “Have you found the hospital satisfactory in its care of the patients ?” This was followed by five answers graded from “very satisfactory” to “unsatisfactory” and the person was asked to say which of the answers expressed his view best. A specially designed card with edge punched holes was used for recording the interview; the comments were written on it during the interview, sometimes verbatim. If necessary a second and third card were used. The holes were clipped to record personal particulars and the comments made. Comments were classified under ten topics and 43 sub-headings. Each sub-heading had two holes allotted to it, one for favourable comments and the other for suggestions or criticisms. This allowed for easy hand sortation for subsequent analysis. Interviews with patients generally took from 20 to 30 minutes though others took up to two hours and patients would sometimes write or telephone to the interviewer afterwards with supplementary points. With staff the interviews tended to be longer: with senior staff they generally took between an hour and three hours. At the start of the survey at each hospital every effort was made to win the interest and co-operation of the staff. After discussions with the chief officers, meetings were usually held with the medical staff, the sisters, the student nurses and, at one hospital, with department heads responsible to the secretary. Many

DO WE KNOW

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211

opportunities were taken for further discussions with staff particularly interested. At the end of the survey at each hospital a report was prepared summarizing anonymously the comments made, both appreciative and critical, and an effort was made to write the report in such a way as to facilitate action. In addition findings were fully discussed with the principal officers. At two of the hospitals lengthy meetings were held with the House Committee. In all but one of the hospitals the survey has resulted in considerable action and at two of the hospitals the interviewer was urged to return to hold surveys in other sections of the hospital.

Sample seen The survey was held in four similar general hospitals one in each of the Metropolitan Regions. All had about 400 beds, had student nurse training schools but not medical schools, were founded last century and were housed in old buildings partly modernized. All four of the hospitals first approached accepted the suggestion to have a survey. Within each hospital patients and staff were seen from nine wards, two medical, one surgical, one orthopaedic, for both men and women, and a gynaecological ward. When there was a choice of such wards those were selected where the sister’s surname came first in the alphabet. This may seem to be an unorthodox method of sampling but it had the great merit of being easily understood. All the patients were invited to participate who had been in these wards four days or more and were, in the opinion of their sister, well enough to be seen. Less than two per cent of these patients did not want to be interviewed and these mainly because they were in pain or tired. Many of the patients expressed pleasure at being asked to give their views. The nurses, nursing auxiliaries, orderlies and domestics attached to the nine wards were also interviewed. In addition senior administrative nursing staff were seen and a sample of the night nursing staff of all levels of seniority. The group and hospital secretaries were interviewed and a stratified sample of those members of the staff responsible to them who had contact with the patients. These included members of professions supplementary to medicine (physiotherapists, occupational therapists, hospital social workers, pharmacists, etc.) and some members of the catering staff, chaplains, librarians, porters, etc. The head of each department was seen and a random sample of assistants. Among those staff invited to participate less than one per cent refused. It was more difficult to get a representative sample of the medical staff. The chairman of the Medical Staff Committee at each hospital was asked for the names of the medical officers (consultants, registrars and housemen) who had the closest association with the hospital. A letter was sent to each of those often following up by a telephone call and about 70 per cent of them agreed to be interviewed either at the hospital or at their consulting rooms. Interviews were sought with the members of the House Committee at each hospital and with the chairman of the Hospital Management Committee and many were seen either at the hospital or at their homes. Although they were almost all willing to be interviewed a number said it would be useless as they had only recently joined the committee or knew too little of the conditions for patients to
WINIFRED

212

RAPHAEL

views. At Hospital D there had recently been a reorganisation only two members of the old committee remained. The number

of people interviewed TABLE

Group

Seen

Patients Nurses Orderlies, etc.* Administration, etc.t Doctors Committee members

I.

Hospital

A

NUMBER

is shown in Table

of the group and

1.

OF PEOPLE INTERVIEWED

Hospital

R

Hospital

C

Hospital

D

Total

110 98 24 18 13 13

144 88 16 18 14 10

122 82 23 24 11 9

122 65 25 28 10 2

498 333 88 88 48 34

276

290

271

252

1089

*Orderlies, etc., includes nursing auxiliaries and domestics. tAdministration, etc., includes lay administrators, professions supplementary responsible to the secretary.

to medicine and other staff

Advantages and limitations of the survey method used The technique for surveying attitudes by unstructured interviews instead of using a questionnaire was chosen with appreciation of its limitations as well as its advantages. Its main value was that information was obtained about the matters that arose spontaneously in the minds of those seen thus giving an indication of the relative significance of different topics with the group concerned. Questions inevitably suggest the topics to be discussed but in an unstructured interview matters are only discussed which the individual himself thinks sufficiently important to raise. Often matters were brought up that came as a complete surprise to the interviewer and would probably not have been included in a questionnaire even after a pilot trial. As invitations to participate were issued several hours before the interview people had time to consider the matters they wished to raise and many people had obviously given the subject a lot of thought. Disadvantages of the unstructured interview method compared with questionnaires are that it takes much time both in interviewing and in analysing results, that it is less suitable for statistical treatment and more susceptible to investigator bias. There were certain advantages in holding the patients’ interviews at the hospital instead of seeing them at home after they had been discharged. Obvious benefits were the convenience and the complete sample obtained. It was useful to see people when the impact of the conditions was strongest and not recalled afterwards in Also it enabled patients to be seen at all stages of their another environment. illness, ,and even those with terminal illnesses were included. Before the survey it was feared that it might be a problem to obtain privacy for patients to talk in confidence but in practice this seldom proved difficult. Many patients were up and were seen in a side room or a quiet corner of the ward and those still in bed often had a neighbouring bed empty. Staff and committee members were either interviewed in their own office or, more often, in an office lent by the hospital to the interviewer. Another fear was the possibility of collusion-of a group of patients or staff

DO WE KNOW WHAT

THE PA’TIE.NTS THIJVK?

210

combining to plan a campaign. Experience with attitude surveys in industry as well as in hospitals suggests that collusion is rare and easy to spot as people usuall) bring up points in the same order and use the same form of words. Only three instances of collusion were spotted during these surveys (two with patients and one with student nurses) in each case on a very small scale. Over-all

Satisfaction

of Patients

“The nurses here are walking angels and my doctor was wonderful at telling me about my illness. My bed is comfortable but the food is stone cold and there is only one bathroom for twenty people”. How satisfied is this patient? Will an over-all summary of his level of satisfaction have any meaning at least for comparing the views of different groups? Each person seen in the survey, whether a patient or a member of the staff or committee, was asked to give, in confidence, a general judgment of how well the hospital was doing its primary job of caring for the patients by choosing one of five answers about conditions for patients. They were “satisfactory on the whole”, typed on a card “very satisfactory”, “satisfactory”, “only fairly satisfactory” and “unsatisfactory”. Under two per cent of the 1089 people seen failed to answer this question. The percentage of people in each group selecting the highest rating “very satisfactory” has been used as a measure, admittedly crude, of the over-all satisfaction of the group and is referred to as the group’s “satisfaction ratio”. Almost three-quarters of the patients chose the highest rating “very satisfactory”. Patients at the four hospitals had very similar satisfaction ratios-- 76 per rent, 75 per cent, 73 per cent and 69 per cent. TABLE 2.

DISTRIBUTION OF RATINGSISYPATIENTS

Rating Very satisfactory Satisfactory Satisfactory on the whole Only fairly satisfactory Unsatisfactory Total No rating

Number

Per cpnt

359 68

73

51

10

14,

13 2

3 0

493

100

5

Was this high level of favourable rating due to politeness or fear of being critical or was it a genuine opinion? It is impossible to be certain but a strong impression was received that it was the sincere view in the vast majority of cases. So often the judgment was given with an explanation: “The hospital has been wonderful in the way it has taken care of me”, “I wouldn’t go to any other hospital if I could help it”, “you couldn’t get better treatment if you paid El00 a week” was said spontaneously. The two patients who gave the rating “unsatisfactory” both thought they had reason to be dissatisfied with the medical treatment given.

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The satisfaction ratio was calculated for groups of patients classified by sex, age, medical condition, socio-economic grade (for men), length of stay and previous experience of being in hospital. Men and women patients

The two sexes gave very similar satisfaction ratios-the 216 men patients had a ratio of 74 per cent and 277 women patients had a ratio of 72 per cent. This absence of significant difference is contrary to the opinion sometimes expressed in the nursing profession that men patients tend to be more contented than women patients. Indeed this difference might be expected if contentment is related to the amount of nursing care given. Male and female wards with comparable numbers of beds were generally allocated the same number of nurses, yet investigations have shown that female patients require more nursing time per patient especially because of the toilet facilities required. @) Age of patients

The old ones were the most contented ones. A strong, highly significant relationship was found between the age and the satisfaction ratios of the patients. This held consistently in all four hospitals both for men and for women. TABLE

3.

RELATIONSHIP Men

Age 15-39 years 40-64 years 65 years or more Total

%

OF PATIENTS' AGE AND SATISFACTION RATIO

(No.=216) Sat. ratio

Women %

(No. =277) Sat. ratio

Total o/ /0

(No. =493) Sat. ratio

26 48 26

54 77 91

25 34 41

51 75 82

26 40 34

52 76 85

100

74

100

72

100

73

(It was interesting, incidentally, to see the different age distribution of the two sexes-a similar proportion were young but almost half of the men were middleaged, and a large proportion of the women were elderly. Female longevity is well known but are we getting close to the situation pictured by L. E. Jones, “If Death were truly conquered

there would be

Too many great great great great aunts to see”. ?) What were the reasons for this striking relationship between age and satisfaction ? Perhaps the best clues were given in the comments of many young people which showed that they, especially, longed to be back in their jobs and with their family and friends. It was the pull from outside that was particularly strong with them rather than dislike of the hospital as such. Medical condition

At each hospital patients were interviewed in four medical wards, two surgical wards, two orthopaedic wards and one gynaecological ward. In the medical and

DO WE KVO W WHAT TABLE 4.

THE PATIEYVTS

RELATIONSHIP OF MEDICAL CONDITION AND

Type of ward Surgical Medical Orthopaedic Gynaecological

THIJVK?

215

SATISFACTION RATIO

No. of patients

Satisfaction ratio

112 229 100 52

80 75 70 56

493

73

surgical wards the men and women tended to be similar as regards age and condition but the male and female orthopaedic wards were quite unlike each other. In the male wards nearly half of the patients (47 per cent) were in the youngest of the three age groups while in the female wards nearly half (again 47 per cent) were in the oldest group. The male wards were largely influenced by “ton-up-boys” suffering from multiple injuries from crashes and young men who had industrial accidents-both groups impatient to be up and about. The female wards contained many quiet old ladies often with fractured femurs, a proportion of whom had no urgent desire to leave the hospital. It is not surprising therefore that the satisfaction ratio for female orthopaedic wards was 80 and for male orthopaedic wards 59. The patients in the gynaecological wards also had their particular problems, often unhappy ones. Many had fears of the future and of the effect of their condition on their marital happiness or their hopes of maternity. The patients tended to be young-61 per cent were aged 39 or less. Since a high proportion of the patients were young in the male orthopaedic and in the gynaecological wards it seemed worth investigating whether their relative discontent was entirely due to their youth or whether other factors were responsible as well; so comparisons were made with patients of similar age groups in other wards. The numbers were too small to be able to generalize with conviction but there appeared to be a tendency for young men from the orthopaedic wards to be less happy than young men from other wards and possibly for middle-aged women from the gynaecological wards to be less happy than other middle-aged patients. The reasons for personal unhappiness in both these wards are clear and many patients found it difficult to differentiate between their general state of mind and their views of the care given to them in hospital. Socio-economic

grade

How does social background and level of occupation influence a patient’s view of the care given to him in hospital ? All male patients were asked about their occupation at the start of the interview and were divided into five groups according to the Registrar General’s classification of socio-economic groups. (In this classification women are grouped by their husband’s or father’s occupation which made it impracticable to include them in this part of the enquiry). Patients from both extremes, classes I, IV and V, tended to be more satisfied with the care given to them than patients from the two middle classes, II and III. It was noticeable that patients from classes IV and V were often particularly

WINFRED

216 TABLE

5.

RELATIONSHIP

RAPHAEL

OF SOCIO-ECONOMIC

GROUP

AND

MALE

PATIENTS'

SATISFACTION

Socio-economic group (examples only) Class Higher professional, Administrative Civil Service I. II. Lower professional, business managers III. Clerical, sales, skilled operatives IV. Semi-skilled operatives, gas, water, electricity workers V. Labourers, unskilled

Per cent Male patient

Sat: Ratio

9 15 45 20 11

85 72 58 81 87

100

74

appreciative of the nursing care and also of the food: “good food and plenty of it” was almost a stock phrase, and they were less ready to criticize any aspect of the hospital. The people from class I often expressed surprise and pleasure at the quality of the care given. Some of them had come in as casualties and said they had first thought of asking to be transferred to a private nursing home but had changed their minds. Other professional people, often retired and comparatively impoverished, said how gratified they were at the courtesy received. The two grades II and III who were less contented perhaps tended to be more status conscious and to make unfavourable comparisons with the high standards of comfort and of food in their own homes. Length of stay and previous experience of hospitals A comparison was made of the views of patients who had been in the hospital for less than a fortnight and those of the longer stay patients. However no difference was found in the satisfaction ratios of the two groups. It was 73 per cent both for the 210 patients who had been in the hospital under a fortnight and for the 283 patients who had been there for a fortnight or longer. The patients were all asked about their previous experience of hospital life. No significant differences were found in the satisfaction ratios of those who had never been an in-patient before and those who had stayed either in their present hospital or in any other hospital. Comparison with a teaching hospital Obviously the findings of this survey can only be taken to apply to the type of hospital surveyed-non teaching general hospitals in London. Since finishing this survey the same interviewer conducted a similar attitude survey with patients in one of the large London teaching hospitals. It is interesting to note that though the satisfaction ratio of the patients was higher the variations between different groups of patients were exactly parallel with those found in the regional board hospitals as regards age, medical condition and socio-economic class. The only difference in the teaching hospital was that the male patients were significantly more contented than the female,

DO WE KNOW

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217

Over-all Satisfaction of Staff and Committee Members

The patients were far happier about the care given to them in hospital than the staff and committee members were on their behalf. The patients had a satisfaction ratio of 73 while that of the whole group of staff and committee was 34-less than half as much. TABLE6.

DISTRIBUTION OF RATINGS MADEBY PATIENTS, STAFFANDCOMMITTEE Patients

Doctors

Nurses

Number

493

48

Percentage rating V. satisfactory Satisfactory Sat. on the whole Only fairly sat. Unsatisfactory

73 14 10 3 0 100

Orderlies etc. 88

Cttee.

332

Admin. etc. 83

21 37 34 6 2

29 36 32 3 0

23 47 29 1 0

64 18 11 5 2

54 33 10 3 0

100

100

100

100

100

30

Doctors. The medical staff, as several of them said, were all familiar with teaching hospitals with their higher staff-patient ratios and better physical environment. They were bound to draw comparisons with these which perhaps explains why, as ‘This hospital a group, they were the most critical of conditions for the patients. is pretty good but the buildings are out of date and we are woefully short of medical and nursing staff, so I can only rate it “satisfactory on the whole”’ was a typical remark from a doctor. Of the 48 doctors seen 29 were consultants whose satisfaction ratio was 24 per cent. The small group of 19 registrars and housemen had a satisfaction ratio of only 16; indeed they were the only group where the medium rating fell as low as “satisfactory on the whole”. Many of them spoke unhappily about the shortage of medical staff affecting the standard of medical care.

Jvurses. The satisfaction ratio of the trained nurses was almost double that of the student nurses. Of the 157 trained nurses 38 per cent said the care of the patients was “very satisfactory” but of the 175 student nurses only 21 per cent said so. This difference may be due to the tendency for younger groups to be more critical than their elders: that was also found with patients and medical staff. Only six out of every ten student nurses interviewed came from the United Kingdom or Eire, but of the trained nurses only ten per cent had come from overseas. However the ratings of the home students and the overseas students were almost identical. Many of the students were deeply concerned with the effect on the patients of a student nurse being left alone for long periods at night in charge of a ward, and of the differences between the nursing methods taught in training school and those used in the wards. Administrative staf including professions supplementary to medicine and other staff responsible to the Secretary. This very assorted group included some staff who were closely in touch with the patients such as hospital social workers and

218

WIflIFRED

RAPHAEL

physiotherapists and others who were more remote such as the hospital secretary, catering officers and head porters. Some members of this group found it difficult to give a rating on the general care of the patients and those who did rate sometimes stressed the care given by their own departments. As many of these were understaffed or had poor premises, the satisfaction ratio tended to be low-23 per centlowest of any group except the doctors. Orderlies, nursing auxiliaries, domestics, etc. This group gave a satisfaction ratio of 64, highest of any group except that of the patients. Indeed throughout the survey it was found that the views of this group corresponded most closely with those of the patients. Patients often chat easily and informally to members of this group of staff who are thus in an especially good position to know the views of the patients. Many of the auxiliaries, orderlies, and domestics were mature women with long service who had an almost maternal attitude to the patients. Committee members. In this small group of 30 people a few members from each hospital seemed really familiar with the conditions for the patients in the wards. The other committee members tended, apologetically, to confine their remarks mainly to structure of the hospital and its reputation in the neighbourhood. Their satisfaction ratio of 54 shows that they were more optimistic about the conditions for the patients than the staff were, except for the orderlies. Projection of Patients’ Over-all Satisfaction onto their Views on Food

A comparison was made of the views of patients in the two “happiest” wards and the two “least happy” wards in each of the four hospitals as assessed by their satisfaction ratios. There was a marked difference between the eight happy and the eight unhappy wards in their comments on food. With the happy wards 66 per cent of the comments were favourable. With the unhappy wards only 36 per cent were favourable. Within each hospital the wards had identical food issued from a central kitchen and transported to the wards in heated trolleys. One is forced to assume therefore that the patients had projected their over-all satisfaction or dissatisfaction onto their views of the food received. There were striking differences between the views of the patients in the happy and unhappy wards on other topics also, especially on ward equipment and on ways of passing time, but with these the objective situation was possibly different, whereas with food it was virtually the same. Proportion of Favourable Comment on Various Topics

No questions were asked in this survey to suggest the topics to be discussed. Over 8000 comments were contributed during the survey-3200 from patients and 4963 from members of the staff and committees. The comments were classified under ten topics divided between three main headings. The Care of the patients

Nursing care. Medical care. Care by people other than nurses and doctors. Communications.

DO WE KNOW

WHAT

THE PA TIEJVTS THINK?

The patients pkysical environment

Ward. Equipment. Hospital apart from ward. The patients’ l;fe in hospital

Social atmosphere. Food. Ways of passing time. The following table shows for each group the proportion of comment that was favourable for the different topics and in total. The fact that a comment was classified as “critical” does not necessarily mean that the situation was altogether bad but that a suggestion was made for improving it. For example, many people who warmly praised the nursing added the comment that more nurses were required so that the nurses need not work so hard. This latter comment counted as criticism and, of course, reduced the ratio of favourable comment on nursing care. TABLE

7.

PERCENTAGE

FAVOURABLE FAVOURABLE

GIVEN GIVEN

BY BY

PATIENTS

(IN

ORDER

Patients

Doctors

Nurses

498

48

333

95

82 82 41 58 15 41 30 21 20 45

80 89 40

43

45

No. in group Topics Medical care Social atmosphere Care by other people Nursing care Communications Food Equipment Ward Hospital apart from wards Ways of passing time

85 79 58 57 42 36 34 33

53 61 39 49 36 37 46 19 7 47

Total

61

40

comments

*Not enough comments to calculate

94

percentage

OF PROPORTION

PATIENTS)

Admin etc. 88

52 15 50 37 28 15 36

Orderlies etc. 88

Committee 34

77 94 41 78 *

!Jl 33 85 *

62 33 31 25 50

78 53 37 14 65

60

60

76

favourable.

It is interesting to compare the totals on this table with Table 6, and to see how in both tables patients were the most satisfied group, followed closely by orderlies and committee members. Nurses and administrators were much less satisfied with the conditions for patients, and doctors were the most dissatisfied group. Looking at the individual topics it can be seen that the less satisfied with “ways of passing time” than the staff and were for them. Both patients and staff were less satisfied than food, equipment and nursing care. It was rather surprising more satisfied with “communications” than the staff were on

patients were much committee members the committee about that patients were their behalf.

WINIFRED RAPHAEL

220

The Most Important Change

When at the end of each interview the question was asked, “What is the most important thing to change in the hospital from the patient’s point of view?” 72 per cent of those seen were able to make a choice of the suggestion that seemed most urgent to them. TABLE

8.

PERCENTAGE

OF INDIVIDUALS

GIVING “MOST

IMPORTANT

CHANGE"

UNDEK

EACH

MAIN AREA

Admin etc.

Orderlies etc.

277

76

54

19*

43 51 6

25 38 37

22 49 29

28 33 39

5 90 5

100

100

100

100

100

Patients

Doctors

312

47

15 26 59 100

No. in group

Nurses

Committee

Main area for alteration The care of the patients Physical environment Life in hospital

*There

were only 19 committee

members responding so these figures are not reliable.

A striking difference was seen between the priorities of the patients and of those who care for them. Well over half of the patients made suggestions on changes affecting their daily life in hospital. The nurses and orderlies considered this area fairly important but the doctors and committee members hardly mentioned it. The two latter groups and the administrative group gave most suggestions in the area of physical environment. Life in hospital This food.

composite

heading

included

such matters

as ways of passing

time,

and

Ways of passing time. More urgent alterations were suggested by patients under this heading than under any other but comparatively few were made by the staff and none by the committee members. Television is so much a way of life for many Patients realized the difficulties of having people that its absence was felt acutely. television aloud in wards where some people were acutely ill but wished that either it could be in day rooms, a central T.V. room or “piped” sound. Radio was available in nearly all the wards but there were many comments that it was out of order or that only one station was available. Visiting hours was another topic raised by many patients. Few, if any, suggested unlimited visiting but they wanted the halfhour’s evening visiting extended to one hour and permitted on days when afternoon visiting was allowed. Boredom was said by patients to be one of the worst aspects of being in hospital-“the days are terribly long”-and they wished that more occupations could be organized for those well enough to participate and that there were more opportunities to go out on balconies or, where possible, in the garden. A few patients criticized the early hours of waking, but more disliked the early hour of “lights out” and lack of opportunity for resting quietly during the day. These

DO WE KNO W WHA I THE PA TILGVTS THINK?

221

suggestions, that the patients considered of prime importance, were not mentioned at all by the committee members and few were mentioned much by the staff except for some nurses who were concerned about the early waking hour. Food. The patients’ suggestions about improving food came only second in frequency to suggestions about ways of passing time although, as we have said earlier in this article, it was related to their more general attitude to the hospital. However, taking suggestions about food at their face value, the patients emphasized the need for better cooking, more choice and warmer meals. The nurses and orderlies were also emphatic on the need for improved quality of the food especially of diet meals but it was not mentioned by the doctors. Staff seldom mentioned that the food was often cold. one matter under this heading Physical environment. The patients emphasized far more than any other-the need for improved sanitary annexes. They spoke of the horror of queueing for lavatories and washbasins when they were feeling ill, of the poor heating, the lack of privacy (no locks on lavatories and no curtains around washbasins) and the need for minor conveniences, such as shelves for shaving tackle and hooks for dressing gowns. The need for improved sanitary accommodation was realized by some of the staff especially the orderlies and also by the committee members but the desire for greater privacy had not occurred to them. Patients also disliked noise especially from outside the wards, such as deliveries of goods and noisy lifts, and also the sounds made by cleaning and polishing machines--“they drive me up the wall”. These points were also made by the staff. On the whole patients were satisfied with their beds except for the rubber undersheets which rucked up and were hot-a point never mentioned by the staff. Aspects of the physical environment stressed by the staff and committee members such as the need for redecorating wards, dividing wards into smaller units, more space between beds and the provision of side-rooms were hardly mentioned by the patients. Care of the patient. The need for more nurses was emphasized by patients and all groups of staff but was not mentioned as the most important change by a single committee member. The patients said “the nurses were worked to death”, and were particularly apprehensive about the situation at night when often a single student nurse was left alone in charge of a ward for long periods. The nurses echoed the patient’s fears on the shortage of nursing staff and were supported in this by doctors, administrative staff and orderlies. In the two hospitals where there were three nurses at night between two wards the situation was far worse than in the two others that had two nurses or a nurse and an orderly per ward. The doctors were the only group which emphasized the need for better medical care and the orderlies spoke of the need for their numbers to be increased. It is perhaps natural that each group of staff considered improvement in its own services to be the most important change to benefit the patients, while the patients thcmselves hardly mentioned need for changes in the care given to them (apart from nursing care) but concentrated their suggestions for change around their daily life in the hospital. Conclusions

In this short article it was not possible to give an account of the 8000 suggestions given during the survey but brief summaries have been published elsewhere. (2,8)

222

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RAPHAEL

Although the findings of the survey can only be applied to the type of hospital concerned it is interesting to see the contrast in attitude of different groups of patients and even more important to note the difference in priorities for change between the patients, the staff and committee members. Many of the improvements most emphasized by the patients could be introduced without expenditure of money or staff time, if they were realised by those who care for them. Such a survey is a practical method for improving communications. References 1.

A. N. EXTON SMITH, D. NORTONand R. MCLAREN, An Investigation of Geriatric Nursing Problems in Hospital, National Corporation for the Care of Old People, Nuffield Lodge, London, NW 1, (1962).

2.

W. RAPHAEL, Patient care: What do the others think? Jvurs. Times, November 26, December 3, 10, 17, 24, 31 (1965).

3.

W. RAPHAEL, If I could alter one thing . . . . Mental Hlth. April (1965).

R&urn&-Un sondage d’opinion a recemment CtC entrepris dam quatre hopitaux gCnCraux de Londres pour comparer les avis des malades concernant leur bien-&tre en hopital avec ceux du personnel et des administrateurs portant sur la situation des malades. Ceci a dtt suivi de deux questions, l’une concernant le degrt de satisfaction g&i&ale, l’autre au sujet des changements consider& les plus necessaires. Pas moins de 498 malades et 591 membres du personnel et des comitts d’administration ont CtC interview&. Le degre de satisfaction g&&ale concernant les soins que reqoivent les malades Ctait de loin plus marque parmi les malades memes que parmi ceux qui s’occupaient d’eux. Le contentement qu’exprimaient les malades rtfletait leur age, leur &at medical et le groupe social auquel ils appartenaient. Les mtdecins representaient le groupe le moins satisfait des soins donnts aux malades et les ttudiantes infirm&es Ctaient de loin moins satisfaites de ces soins que les infirmities formees. On decouvrit que le contentement general affectait les opinions au sujet de la nourriture. M&me dans le cas de salles d’hopitaux recevant une nourriture identique, deux tiers des observations faites par les malades au sujet de la nourriture etaient favorables dans les salles penchant vers la satisfaction tandis que seulement un peu plus d’un tiers des commentaires ttaient favorables dans le cas des salles moins satisfaites. Un depouillement des 8000 rtponses a Ctt entrepris, et il s’est avert que le personnel et les administrateurs ont particulierement souligne, parmi les chases qu’il Ctait important de changer, le besoin de modifier l’ambiance physique. Tous les groupes ont appuyt sur Pamelioration souhaitte des lieux sanitaires mais seuls les malades ont demand6 que ces endroits soient plus priv&s. Les commentaires des malades soulignent la necessitt de modifier la vie quotidienne des hopitaux-sujet B peine soulevt par les docteurs et administrateurs. Les malades voulaient avoir plus a faire, recevoir davantage des visites et jouir d’un meilleur choix de nourriture. Tous les groupes, a part les administrateurs, signal&rent la p&urie d’infirmieres, particulitrement pendant la nuit. Resumen-FuC realizada una encuesta en cuatro hospitales generales de Londres, para comparar 10s puntos de vista de 10s pacientes sobre sus condiciones en el hospital, con 10s puntos de vista de 10s miembros de la plantilla y de1 comite acerca de las condiciones de 10s pacientes. El metodo usado fut la interviu individual no planeada. Esta fuC complementada con dos preguntas, una sobre la satisfaction en general, y

DO WE KNOW

WHAT

THE PATIENTS

THINK?

223

otra sobre el cambio considerado mls importante. Las intervius fueron celebradas con 498 pacientes y 591 miembros de la plantilla y de1 comitt. En general la satisfaction acerca de1 cuidado de 10s pacientes fuC largamente superior entre 10s pacientes que entre quienes estaban a su cuidado. Con la satisfaction de 10s pacientes estaba relacionada la edad, la condition mtdica, y el grupo socio-econdmico. Los doctores eran el grupom enos satisfecho con el cuidado de 10s pacientes, y las enfermeras estudiantes estaban mucho metros satisfechas con Cl, de lo que lo estaban las enfermeras ya adiestradas. Result6 que la satisfaction general era proyectada sobre cuestiones de comida. Aim cuando las salas recibian comida idtntica, en las salas mis satisfechas dos tercios de 10s comentarios hechos por 10s pacientes sobre la comida eran favorables, mientras que en las salas menos satisfechas solamente alrededor de un tercio de estos comentarios eran favorables. Fut realizado un analisis de 10s 8000 comentarios recibidos, y de entre equellas materias consideradas coma mis importantes para modificar, 10s miembros de la plantilla y de1 comitt subrayaron m&s fuertemente la necesidad de cambios en el ambiente fisico. Todos 10s grupos resaltaron la necesidad de mejor acondicionamiento sanitario, pero solo 10s pacientes habiaron acerca de la necesidad de mayor intimidad. El comentario de 10s pacientes resaltaba la necesidad de cambios en su vida diaria en el hospital-una cuestion que era fuertemente mencionada por 10s doctores y miembros de1 comite. Deseaban mayor ocupacion, m&s visitas, y superior variation de comida. Todos 10s grupos, a exception de 10s miembros de1 comitt, hablaban de la escasez de enfermeras, especialmente por la noche.

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