Patient Satisfaction in Oncology Ward Settings in Saudi Arabia

300 Pages·2016·2.7 MB·English

Patient Satisfaction in Oncology Ward Settings in
Saudi Arabia: A Mixed Methods Study

Manal Saeed Banaser

Thesis submitted for the degree of Doctor of Philosophy
School of Health Sciences
University of Stirling

June 2016
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DECLARATION
I declare that this thesis is my own work and has submitted only for the degree of PhD in the
University of Stirling.

Manal Banaser
June 2016

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ACKNOWLEDGEMENTS
My gratitude to Allah almighty God for seeing me and supporting me during this PhD
journey. Thanks for helping me to complete this thesis.
I would like to express my special thanks to my PhD supervisors Dr. Kathleen Stoddart and
Dr. Nicola Cunningham for sharing their specialist knowledge, and providing invaluable
advice, support and encouragement during my PhD journey. Without their continuous belief
in me this thesis would not have been possible. I am deeply appreciative of their patience,
kindness and understanding throughout, but especially during the final stages of this thesis.

I am very grateful to my external examiner: Prof. Alison Richardson, University of
Southampton; and the external examiner Dr. Fiona Harris, University of Stirling for their
critical discussion and comments during my viva and for guiding me through the required
changes and revisions.

I am indebted to Dr. Josie Evans for sharing her expertise and knowledge in the quantitative
analysis field. I would like to thank the nursing department administration staff, in particular
Evonne Fleming for being instrumental in the smooth running of my PhD studies. I would
also like to thank my fellow PhD students at the School of Health Science for their
friendship, kind support and shared experiences.

I would like to thank the officials at the Saudi Cultural Bureau Office in London for their
support, understanding and provision of financial support and administrative assistance
during my PhD journey here in Stirling. I would also like to thank the nursing director at the
Saudi regional cancer centre in Riyadh for her assistance with the collection of data. Many
thanks also to Ms. Daad Salhab for her effort and time during the data collection. Special
thanks also to all research participants who took part in my study and provided their time to
share their insights with me.

I would like to express my special thanks to my husband, Mesfer AlQahtani, for his
outstanding support, love, understanding, encouragement and humour during the highs and
lows of my PhD experience and throughout the final challenging stages when submitting this
thesis. I would like to dedicate this thesis to my beautiful daughter, Marah, who has spent
considerable time in nursery so I could focus on and complete this thesis. Her smiles and
laughter have been a constant inspiration.

I also want to dedicate this work to my parents. I am eternally grateful to my father, Saeed
Banaser, who is the most inspiring person in my life. His continuous encouragement,
support and kind words led me to pursue my PhD ambition at the very start, and have
helped me work through difficult times towards final submission of this thesis. This thesis is
also in remembrance of my mother, Alia Bayameen, whose loss provided the incentive and
determination to pursue my PhD studies. Finally, I want to express my special thanks to all
my family, sisters and brothers for their ongoing support which has enabled me to complete
my studies abroad.

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ABSTRACT
Background: Since the 1980s, Saudi Arabia‘s socio economic transformation has led to
vast social development. As a result there has been increased adoption of behaviours such
as smoking and sedentary life styles, which pose a risk to health. It is anticipated that cancer
incidence will double over the next two decades and it is thus vital that high quality of care is
provided to meet the growing health care demands. Moreover, it is important that patients
are satisfied with their care provision. This thesis begins with a narrative synthesis of the
existing literature about patient satisfaction in the Saudi context and beyond. An evaluation
of the key concepts for understanding patient satisfaction illuminated the lack of evidence
about the assessment of patient satisfaction including specific key domains of the structure
and process of care. This evaluation also indicated the need to further investigate the Saudi
patient perspectives in oncology hospital setting. The aim of my study was to examine the
extent to which clinical effectiveness impacts upon patient satisfaction in oncology ward
settings in the Kingdom of Saudi Arabia (KSA).

Methods: A sequential explanatory mixed methods design was employed. The Donabedian
quality framework (1980) and Patient experience model (Reimann and Strech 2010) were
used to assess patient satisfaction with quality of care provided. A quantitative phase was
followed by a qualitative phase. In the first phase, the European Organisation for Research
and Treatment of Cancer (EORTC) IN-PATSAT32 validated questionnaire was used to
collect data from 100 adult oncology inpatients at a Cancer Centre in Riyadh. The second
qualitative phase involved semi-structured telephone and face to face interviews with 22
adult oncology inpatients who previously answered the questionnaire. Synthesis occurred at
the intersection of quantitative Phase 1 and qualitative Phase 2 data. The qualitative Phase
2 thus further explored the satisfaction scores of quantitative Phase1 to deepen the
understanding of patient satisfaction in oncology ward settings in KSA.

Findings: The main findings were that patient satisfaction levels are influenced by the
clinical effectiveness of doctors and nurses, accessibility to health care and socio-
demographic factors. Specifically, the interpersonal aspects of care were deemed core to
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patient experiences in oncology ward settings in KSA. It emerged that doctor-patient
relationships, nurse shortages and language barriers are particular areas where changes
could be made to improve care, thereby enhancing patient satisfaction. These findings
contribute important new insights into the interpersonal aspects of care in the light of the
underlying social and cultural contextual factors that influence patient satisfaction in the
KSA.
Conclusion: This study has provided new evidence supporting the need for stronger
interpersonal relations and a more patient-centred approach in the oncology health system
in KSA. In particular, the influential role of cultural issues in influencing patient satisfaction in
oncology ward settings was apparent. Evidence provided by this research will make a
substantial contribution to policy makers and hospital management teams in the KSA
wanting to improve patient satisfaction in oncology wards and in other health care settings.
Keywords: Patient satisfaction, patient experience, clinical effectiveness, oncology, Saudi
Arabia, hospital wards settings

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Table of Contents
Chapter 1 Introduction ....................................................................................................... 12
1.1 Introduction .................................................................................................................................................... 12
1.2 Patient Satisfaction and Quality of Care ........................................................................................................ 13
1.2.1 Quality of Care ........................................................................................................................................ 13
1.2.2 Patient Satisfaction ................................................................................................................................. 16
1.2.3 Patient Experience .................................................................................................................................. 19
1.2.4 Clinical Effectiveness .............................................................................................................................. 22
1.2.5 Perceptions of Care Quality in KSA Context .......................................................................................... 22
1.2.6 Summary ................................................................................................................................................. 23
1.3 Research Aims and Research Questions ...................................................................................................... 24
1.4 Significance of Research ............................................................................................................................... 25
1.5 Overview of Study Context ............................................................................................................................ 26
1.5.1 History and Background of the Kingdom of Saudi Arabia ...................................................................... 26
1.5.2 The KSA Culture ..................................................................................................................................... 27
1.5.3 The Process of 'Saudisation‘ .................................................................................................................. 28
1.6 Healthcare within the KSA ............................................................................................................................. 29
1.6.1 The Doctor-Patient Relationship and Disclosure .................................................................................... 30
1.6.2 Cancer Prevalence and Care of Oncology Patients in the KSA ............................................................. 31
1.6.3 Personal Research Rationale ................................................................................................................. 33
1.7 Outline of Thesis ............................................................................................................................................ 33
Chapter 2 Literature Review .............................................................................................. 35
2.1 Introduction .................................................................................................................................................... 35
2.2 Methodology for Literature Review ................................................................................................................ 35
2.2.1 Narrative Synthesis ................................................................................................................................ 35
2.2.2 Literature Search Strategy ..................................................................................................................... 38
2.2.3 Inclusion and Exclusion of all Search Outcomes ................................................................................... 38
2.2.4 Quality Appraisal .................................................................................................................................... 39
2.3 Overview of Studies ....................................................................................................................................... 39
2.3.1 Quality of Care: Definition and Measurement ......................................................................................... 40
2.3.1.1 Donabedian Model (1980) ............................................................................................................... 41
2.3.2 Patient Satisfaction and Expectations .................................................................................................... 42
2.3.2.1 Definitions ........................................................................................................................................ 42
2.3.2.2 Influences upon Patient Satisfaction ................................................................................................ 45
2.3.2.3 Disclosure Practices ........................................................................................................................ 46
2.3.2.4 Doctor-Patient Relationship ............................................................................................................. 47
2.3.2.5 Patient-Centred Care ....................................................................................................................... 49
2.3.2.6 Measurement of Patient Satisfaction ............................................................................................... 50
2.3.3 Clinical Effectiveness ............................................................................................................................ 53
2.3.1.1 Definition .......................................................................................................................................... 54
2.3.1.2 Measuring Clinical Effectiveness ..................................................................................................... 54
2.4 Patient Satisfaction in the KSA .................................................................................................................... 57
2.5 Perceptions of Patient Satisfaction in Existing KSA Research ...................................................................... 65
2.5.1 Disclosure Practices in KSA ................................................................................................................. 67
2.5.2 Gender Politics ....................................................................................................................................... 67
2.5.3 Respect for Religious Beliefs in KSA .................................................................................................... 69
2.5.4 Doctor-Patient Relationship in KSA ...................................................................................................... 69
2.5.5 Patient-Centred Care in KSA ................................................................................................................ 71
2.5.6 PCC and IOM‘s Six Dimensions of Care Quality in KSA ...................................................................... 75
2.6 Identified Research Gap: Quality of Care Assessment in KSA ..................................................................... 79
2.6.1. Structure ................................................................................................................................................ 79
2.6.2 Process ................................................................................................................................................. 81
2.6.3 Outcomes ................................................................................................................................................ 83
2.7 Working definitions of thesis .......................................................................................................................... 84
2.8 Conclusion ............................................................................................................................................... 86
Chapter 3 - Methodology .................................................................................................. 87
3.1 Introduction .................................................................................................................................................... 87
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3.2 Research Questions and Study Aims ............................................................................................................ 87
3.3 Overview of Mixed Methods Research (MMR) .............................................................................................. 88
3.3.1 Key Issues in Mixed Methods Research ................................................................................................. 89
3.3.2 Sequential MMR Research Design ......................................................................................................... 91
3.3.3 Mixed Methodological Research Strategy Development ........................................................................ 92
3.3.4 Applicability of Sequential Mixed Methods ............................................................................................. 94
3.3.4.1 Timing .............................................................................................................................................. 94
3.3.4.2 Weighting ......................................................................................................................................... 95
3.3.4.3 Mixing ............................................................................................................................................... 95
3.3.4.4Theorising ......................................................................................................................................... 95
3.3.5 Quantitative Research Strategy Development ....................................................................................... 97
3.3.5.1 Online Surveys .................................................................................................................................... 97
3.3.5.2 Hospital Surveys .................................................................................................................................. 99
3.3.6 Qualitative Research Strategy Development ........................................................................................ 101
3.3.6.1 Focus Groups .................................................................................................................................... 101
3.3.6.2 Semi-Structured Interviews ................................................................................................................ 103
3.3.7 Summary of the MMR Approach Taken ............................................................................................... 104
3.4 Phase 1: Quantitative Method ...................................................................................................................... 105
3.4.1 Cross-Sectional Survey Design ............................................................................................................ 105
3.4.2 Sampling Strategy ................................................................................................................................. 106
3.4.2.1 Population ...................................................................................................................................... 106
3.4.2.2 Inclusion criteria ............................................................................................................................. 106
3.4.3 Recruitment Procedures ....................................................................................................................... 107
3.4.4 Sampling Methods and Response Rate ............................................................................................... 109
3.4.5 Quantitative data collection ................................................................................................................... 110
3.4.5.1 Instrumentation ................................................................................................................................. 110
3.4.5.2 Questionnaire Distribution............................................................................................................. 111
3.4.5.3 Cultural Considerations................................................................................................................. 112
3.4.6. Quantitative Data Analysis ................................................................................................................... 112
3.5 Phase 2: Qualitative Method ........................................................................................................................ 113
3.5.1 Semi-Structured Interview Design ................................................................................................. 113
3.5.2 Participant Recruitment .................................................................................................................. 113
3.5.3 Sampling methods ......................................................................................................................... 114
3.5.4 The development of the interview schedule .................................................................................. 114
3.5.5 Qualitative Data Collection ............................................................................................................. 116
3.5.5.1 Telephone interviews ..................................................................................................................... 116
3.5.5.2 Face-to-Face Interviews ............................................................................................................... 117
3.5.6 Interview Process ........................................................................................................................... 117
3.5.7 Qualitative Data Preparation .......................................................................................................... 121
3.5.8 Qualitative Data Analysis ............................................................................................................... 121
3.6.8.1 Thematic analysis using coding ..................................................................................................... 122
3.6 Ethical considerations ............................................................................................................................ 128
3.6.1 Informed consent ........................................................................................................................... 128
3.6.2 Anonymity and Confidentiality ........................................................................................................ 129
3.6.3 Data protection ............................................................................................................................... 129
3.6.4 Cultural and Linguistic Barriers ...................................................................................................... 129
3.6.5 Potential Distress ........................................................................................................................... 130
3.6.6 Researcher Skills and Resources .................................................................................................. 130
3.7 Chapter Summary .................................................................................................................................. 132
Chapter 4 Quantitative Results ....................................................................................... 133
4.1 Introduction .................................................................................................................................................. 133
4.1.1 Missing Data and Response Rate ........................................................................................................ 134
4.2 Socio-Demographic Distribution of Adult Oncology Patients (SRQ1) ......................................................... 135
4.3 Quantitative Metrics of Clinical Effectiveness (SRQ2) ................................................................................. 136
4.4 Impact of Service Organisation on Patient Satisfaction (SRQ3) ................................................................. 139
4.5 Patient Satisfaction ...................................................................................................................................... 140
4.6 Extent of Sub-Scale Impact upon Satisfaction ............................................................................................. 142
4.6.1 Descriptive Summaries .................................................................................................................. 142
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4.7 Summary of Key Results ............................................................................................................................. 144
Chapter 5 - Qualitative Findings...................................................................................... 146
5.1 Introduction .................................................................................................................................................. 146
5.2 Socio-Demographic Contextualisation of Research Sample ....................................................................... 146
5.3 Key Themes from Qualitative Research ...................................................................................................... 151
5.4 Impact of Interpersonal Aspects of Care on Patient Satisfaction (SRQ4) ................................................... 152
5.4.1 The Doctor-Patient Relationship ........................................................................................................... 152
5.4.2 Non-Disclosure ..................................................................................................................................... 153
5.4.3 Listening Skills ...................................................................................................................................... 155
5.4.4 Information Provision ............................................................................................................................ 157
5.4.5 Motivation .............................................................................................................................................. 159
5.4.6 Care and Compassion .......................................................................................................................... 163
5.4.7 Summary ............................................................................................................................................... 166
5.5 The Nurse-Patient Relationship ................................................................................................................... 169
5.5.1 Clinical Effectiveness: The Role of Nurses within the Service Organisation ........................................ 169
5.5.2 Technical Competence ......................................................................................................................... 171
5.5.3 Interpersonal Skills ................................................................................................................................ 173
5.5.4 Care and Compassion .......................................................................................................................... 174
5.5.5 Availability ............................................................................................................................................. 176
5.5.6 Summary ............................................................................................................................................... 177
5.6 Impact of Social-Cultural Communication Factors on Patient Satisfaction (SRQ5) .................................... 179
5.6.1 Patient Perceptions of Cancer .............................................................................................................. 179
5.6.2 Doctor-Patient Power Dynamics ........................................................................................................... 181
5.6.3 Influence of Religion ............................................................................................................................. 184
5.6.4 Influence of Family ................................................................................................................................ 186
5.6.5 Influence of Multi-Cultural Healthcare Environment ............................................................................. 188
5.6.6 Summary ............................................................................................................................................... 189
5.7 Service Organisation Impact on Patient Satisfaction (SRQ2) ..................................................................... 192
5.7.1 Accessibility of Healthcare .................................................................................................................... 192
5.7.2 Waiting Times ....................................................................................................................................... 193
5.7.3 Overarching Assessment of General Service Organisation ................................................................. 196
5.7.4 Summary ............................................................................................................................................... 197
5.8 Summary of Qualitative Findings ................................................................................................................. 199
Chapter 6 - Discussion and Conclusion ......................................................................... 201
6.1 Introduction .................................................................................................................................................. 201
6.2 Overview of KSA Results ............................................................................................................................. 204
6.3 Interpersonal Aspects of Care in the KSA ................................................................................................... 205
6.3.1 The Doctor-Patient Relationship ........................................................................................................... 205
6.3.2 The Nurse-Patient Relationship ............................................................................................................ 209
6.3.3 Cultural Expectations of Care in the KSA ............................................................................................. 213
6.3.4 Summary ............................................................................................................................................... 216
6.4 Implications for Improved Patient Satisfaction in the KSA ........................................................................... 217
6.4.1 Organisational Structure in Oncology Ward Settings in the KSA ......................................................... 217
6.4.2 Process in Oncology Ward Settings in the KSA ................................................................................... 219
6.4.2.1 Adopting Increased Disclosure ...................................................................................................... 220
6.4.2.2 Encouraging Healthcare Training .................................................................................................. 221
6.4.2.3 Improved Service Organisation and Clinical Effectiveness ........................................................... 222
6.4.3 Patient-Centred Outcomes in Oncology Ward Settings in the KSA ..................................................... 223
6.5 Contributions of Research to Existing Literature on Patient Satisfaction in KSA Oncology Ward settings . 224
6.6 Limitations of Research ............................................................................................................................... 227
6.7 Recommendations for Future Research ...................................................................................................... 230
6.8 Conclusions .................................................................................................................................................. 232
REFERENCES ................................................................................................................... 235
APPENDICES .................................................................................................................... 264
Appendix1: Percentage Distribution of Cancer Incidence among Saudis by Sex according to Age Group, 2010
(Saudi Cancer Registry 2010) ............................................................................................................................ 265
Appendix 2: Search and screening process ...................................................................................................... 266
Appendix 3: Inclusion and exclusion criteria of literature search strategy ......................................................... 268
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Appendix 4: Criteria for quality appraisal of chosen studies in literature review ............................................... 269
Appendix 5: Table of included studies ............................................................................................................... 270
Appendix 6: Participant information sheet (patients) ......................................................................................... 288
Appendix 7: Patient consent form ...................................................................................................................... 291
Appendix 8: Recruitment log for patients ........................................................................................................... 292
Appendix 9: EORCT Inpatient satisfaction questionnaire EORTC IN-PATSAT32 ........................................... 293
Appendix 10: Scoring manual for In-patient satisfaction questionnaire ............................................................. 297
Appendix 11: Interview schedule ....................................................................................................................... 299
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LIST OF FIGURES
FIGURE 1- COMBINATION OF DONABEDIAN' MODEL OF CARE AND IOM'S 6 DIMENSIONS OF CARE .. 15
FIGURE 2 - CHARACTERISTICS OF INTERACTIONS (REIMANN & STRECH 2010, P.240) ......................... 19
FIGURE 3 - ORGANISATIONAL ASPECTS (REIMANN & STRECH 2010, P.241) ........................................... 20
FIGURE 4 - OVERARCHING ASSESSMENTS (REIMANN & STRECH 2010, P.240) ...................................... 21
FIGURE 5 - INTEGRATIVE NARRATIVE SYNTHESIS PROCESS (ADAPTED FROM POPAY ET AL. 2006) 37
FIGURE 6 - SEQUENTIAL MMR RESEARCH DESIGN (CRESWELL 2013) .................................................... 92
FIGURE 7 - PATIENT EXPERIENCE RESEARCH STRATEGIES (HEALTH FOUNDATION, 2013 P.30) ....... 93
FIGURE 8 - CORE COMPONENTS OF PATIENT EXPERIENCE (REIMANN & STRECH 2010, P.240) ......... 94
FIGURE 9 - FLOW CHART OF QUANTITATIVE DATA COLLECTION PROCESS ........................................ 134
FIGURE 10 - BREAKDOWN OF PATIENT PARTICIPATION .......................................................................... 135
FIGURE 11-COLLATED RESEARCH RESULTS, ADAPTED FROM DONABEDIAN (1980) .......................... 201
FIGURE 12 - COLLATED RESEARCH RESULTS, ADAPTED FROM: REIMANN & STRECH (2010, P.240) 202
FIGURE 13 - RECOMMENDATIONS AND IMPLICATIONS OF RESEARCH ................................................. 203
FIGURE 14- KEY DETERMINANTS OF PATIENT SATISFACTION IN THE KSA STUDY ............................. 205
FIGURE 15 - IMPLICATION OF RESEARCH IN ONCOLOGY WARD SETTINGS IN THE KSA, ADAPTED
FROM DONABEDIAN (1980) .................................................................................................................... 217

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