CHAPTER 6:DISCUSSION FROM THE QUANTITATIVE STUDY
6.2 Analysis and Discussion of the Quantitative Data
6.2.3 Domains of Patient Experience: Patient Perspective
The discussion that follows groups the domains into three sub-domains according to the Factor Analysis 'Communication, Access and Facility quality', 'Nurse/clinic care' and 'Doctor and Management'.
6.2.3.1 Communication, Access and Facility Quality
The Kruskal-Wallis analysis showed no significant association with age and race toward this grouping. Gender has a statistically significant association with this grouping. Female respondents were less likely to report that the waiting time, physical state of the infrastructure,
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communication quality of care, access and family/friend involvement influence their experience of care whereas male respondents were more likely to report that the above domains were significant predictors of patient experience. These findings provide new knowledge, as other studies have not investigated demographic predictors on the domains that influence patient experience.
• Waiting Time
The majority of respondents agreed that waiting time influenced their patient experience. The factor analysis revealed that waiting time is a significant domain to patient experience as the latent factor value exceeds 0.7. Salam, Alshakiera, Alhadi, Ahmed and Mohamed (2010:1) support that whilst the experience of the quality of care is influenced by technical components such as equipment, it is mostly influenced by non-technical elements such as waiting time and health worker attitude. Similarly, an earlier study (Vadhana,2012:22) "showed waiting time to be a significant factor that caused the majority of the respondents to feel uncomfortable with the services provided". More than three quarter of the respondents from Vadhana's study showed a positive opinion towards services provided in the department but they were disappointed with the very long waiting time to receiving services. These studies support the findings of the present study. Therefore waiting time is included in the development of the conceptual model.
• Quality of Care
The majority of the respondents agreed that the quality of care influenced the patient experience.
The factor analysis revealed that quality of care is a significant domain to patient experience as the latent factor value exceeds 0.7. Quality of health care meets the health needs of the patient at the lowest cost and within the expected professional standards and regulations (Amatya et al., 2017:270). "The patients' satisfaction with the quality of care is the degree to which, the desired expectations, goals and or preferences are met by the health care provider and or service"
(Nnebue, Ebenebe, Adinma, Iyoke, Obionu, Ilika,2014:595). If a gap exists between the patient's expectation and the provision of quality care, it can have a negative impact on the patient's experience of care.According to Khumalo (2010:1), Batho Pele Principles seek to ensure that public servants are service-orientated and strive for excellence. Simply stated Batho Pele emphasises quality and holds public servants accountable for the lack thereof. Importantly there is also a close relationship between quality and waiting time, as reflected in the study by
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Vadhana (2012:25), where patients had a positive opinion towards the quality of services but felt that the long waiting time elicited a negative experience. Quality of care is included in the development of the conceptual model.
• Access
The majority of respondents agree that access influences their patient experience. The factor analysis revealed that access is a significant domain to patient experience as the latent factor value exceeds 0.7. In SA, "access, has been constitutionally mandated as a basic human right, and government should aim to provide universal and equitable access to high quality health care services throughout the nine provinces" (Levesque et al.,2013:12). A survey of public views of the health system showed that patients reported difficulty in accessing care (Stremikis, Schoen and Fryer,2011:4). A failure of government to provide accessible healthcare also leads to vulnerable populations who present with unsatisfactory health care outcomes when compared with the general population. Access is included in the development of the conceptual model.
• Family/ friend Involvement
The frequency analysis revealed that the majority of respondents agreed that welcoming family/friend involvement influenced their patient experience. Whilst the concept of welcoming family and friends is not investigated within the health care environment in SA, the factor analysis revealed that family/friend involvement is a significant domain to patient experience as the latent factor value exceeds 0.7. Therefore, the lack of family/friend involvement can elicit a negative patient experience. According to Rosland, Piette, Choi and Heisler (2011:37) whilst little is known about the level of family/ friend involvement in the healthcare visits of patients and how that involvement affects the experience of patients, their study showed a different perspective of welcoming the involvement of family/friends. The findings of Rosland's study showed that patients were not always comfortable with the presence of the third party in the private consultation and indicated that too much of their personal information, had been divulged. Whilst these findings do not support the involvement of family / friend, the present study supports the involvement of family/friends in the management of the patient. It may also, be argued that in the case of vulnerable populations such as the elderly, children and pregnant women, the use of additional assistance in the form of a friend or family member can help
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lighten the load of care management. The involvement of family/friend is included in the development of the conceptual model.
• Physical State of the Infrastructure
The majority of the respondents indicated that the state of the physical infrastructure influenced their patient experience. The factor analysis revealed that the physical state of the infrastructure is significant to patient experience as the latent factor value exceeds 0.7. This finding is justified by the findings of Ahmad et al. where the physical environment in a public health facility is a major determinant influencing the experience of care (Ahmad et al.,2011:183).The Health Care Facilities Baseline Audit indicate that less than one fifth of health facilities have a suitable infrastructure and these inadequacies therefore lead to sub-standard delivery of care and may contribute to a negative patient and health worker experience. The physical state of the infrastructure is included in the development of the conceptual model.
• Communication
The finding of the study shows that the majority of respondents' indicated that communication influences the respondents' experience of care. However, the factor analysis showed that communication, as an individual domain is not significant as it yielded a value less than 0.7. The factor analysis results can be attributed to the understanding that communication serves as a key aspect within the role of the doctor, role of the nurse, education of the patient, role of medication and the involvement of family/ friend. Therefore, its significance as an individual domain influencing patient experience is less weighty. According to the National Health Care Facilities Baseline Audit (2012:45), "mechanisms to communicate consistently and systematically with patients and to share with communities the results and the progress of quality improvement initiatives are lacking". Bearing in mind that most of this communication takes place through the medium of health professionals, the role of the doctor and nurse is highlighted. Robinson, Callister, Berry and Dearing (2008:602) support communication in its role for a better patient experience. Whilst, communication is noted by other authors for influencing patient experience it is not included in the conceptual model as an individual domain.
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The Kruskal-Wallis analysis finding shows that race did not have a statistically significant association with this grouping. Age and gender has a statistically significant association with this grouping. The younger patients (<30) were less likely to report that the domains in this grouping influenced their patient experience. As the age of the patient increases, the influence of the domains in this grouping on patient experiences increases correspondingly. More male respondents report that the domains in this grouping influence their experience of care. These findings provide new knowledge, as other studies have not investigated demographic predictors on the domains that influence patient experience.
• Clinic Cleanliness
The majority of respondents indicated that cleanliness influenced their patient experience. The factor analysis showed that clinic cleanliness is significant as it yielded a value greater than 0.7.
“South Africa is failing in terms of cleanliness” according to the Operation Phakisa Report (2015:38). The issue of cleanliness is one that demands attention taking into consideration the transmission of infection. Dirty environments and unhygienic toilet facilities are a common occurrence in government hospitals, and contribute towards patient dissatisfaction (Saini, Singh, Parasuraman and Rajoura,2013:114). There is a convergence of the study findings with other authors regarding the state of cleanliness. Cleanliness is included in the development of the model.
• Coordination and Continuity of Care
Almost all the patients have agreed that this domain influences the patient experience. The factor analysis showed that coordination and continuity of care is significant as it yielded a value greater than 0.7. According to Picker Principles the information on discharge and organizing the continuing care as well as whom to call for help supports co-ordination and continuity of care.
According to IOM, "the requirement to ensure that accurate and timely information reaches those who need it at the appropriate time..." also merges with the above statement (IOM,2001:14).
Patients often receive insufficient information about vital aspects of the care management such as progressive steps in their care plan, activities of daily living, side effects or complications for procedures that have been completed, and follow up queries.
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On the other hand, information overload can affect the patient's ability to remember and apply the information when needed (Jencks, Williams and Coleman,2009:1418). Schang et al.
(2013:21) states that "care coordination can be seen as part of a broader strategy to improve quality in health care delivery and, ultimately, to strengthen the performance of the health system". According to Shaw, Rosen and Rumbold (2011:14) "integrated care is a term that reflects a concern to improve patient experience and achieve greater efficiency and value from health delivery systems". The aim is to address fragmentation in patient services, and enable better coordinated and more continuous care. Ho (2014:12) also worked on patient co-ordination and integration at "to improve waiting time and operational clinic flow by optimising the process and rearranging the time. The turn-around time reduced, the percentage of patients seen by the doctor increased and the waiting time reduced ". The benefits of integrated care are clear as reflected by the various literary sources. The domain is included in the development of the conceptual model.
• Role of the Nurse
The majority of respondents indicated that the nurse's role influenced their patient experience.
The factor analysis showed that the role of the nurse is significant as it yielded a value greater than 0.7. In SA healthcare staff are, burdened with the high workloads (DoH,2016:20) and the current patient experience finding indicates that nurses do not provide quality care. Pelzang, et al. (2010:186) explained that the shortage of staff and overworked employees worked against a positive patient experience. The role of the nurse is included in the development of the model.
• Patient Centred Care
The majority of patients revealed that receiving patient centred care influenced their patient experience. The factor analysis provided a contrasting finding in that the domain of patient centred care is not significant as it yielded a value less than 0.7. According to Picker Principles
"this includes the accommodation of family and friends, involving family in decision-making, supporting the family as care-giver and recognizing needs of the family". According to the IOM
"this includes accommodating family and friends on whom patients may rely, involving them as appropriate in decision making, supporting them as caregivers, making them welcome and
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comfortable in the care delivery setting, and recognizing their needs and contributions". The above definitions link patient centered care closely with the involvement of family/friends. This link could possibly explain why patient centered care is not significant as an individual domain influencing patient experience. Patient Centred Care is not included in the development of the model.
6.2.3.3 Doctor and Management
The Kruskal-Wallis analysis revealed that age and gender had a significant association with this grouping. More specifically the patient experience of respondents in the 31-45 age category were mostly influenced by the role of the doctor, education, information, management effectiveness towards producing positive outcomes and the role of medication. Male respondents also reported that the domains in this grouping were influencers of their patient experience. These findings of the present study provide new knowledge, as other studies have not investigated demographic predictors on the domains that influence patient experience.
• Role of the Doctor
The majority of respondents indicated that the role of the doctor influenced their patient experience. The factor analysis showed that the role of the doctor is significant as it yielded a value greater than 0.7. According to Devanny (2015:26) patients want to know that they can trust their doctors with the responsibility of translating clinical data into explanations and treatment options that make sense. Other studies have also highlighted the importance of practitioner- patient interaction, and its influence on the experience of care (Odhayani and Khawaja,2014:24;
Sodani, Kumar, Srivastava and Sharma,2010:52; Muhondwa et al.,2008:67). Galhotra, Sarpal, Gupta and Goel (2013:240) "reported that less than two thirds of patients were satisfied with the advice they received, and 72% felt that the practitioner’s medical skills were satisfactory". A study carried out at by Islam and Jabbar (2008:56) suggested,"81% of patients were satisfied with the responsiveness and patience of the doctors, but 49% were dissatisfied with the lack of explanation or clarity regarding their prescribed treatment". The doctor plays an important role in the patient's experience of care and is included in the model.
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• Education
The majority of patients indicated that being educated about their health influenced their experience of care. The factor analysis showed that the domain of education is significant as it yielded a value greater than 0.7. Educating the patient holds benefits for the patient, service provider and health facility. When patients are educated about the health condition, processes that they will follow and general management of their well-being, they are better positioned for producing positive outcomes (Jha et al.,2017:37). Education of the patients is included in the model.
• Role of Medication
The frequency statistics revealed that the more than ninety percent of patients agreed that the role of medication influenced their experience of care. The factor analysis showed agreement with the preceding finding in that the role of medication is significant as it yielded a value greater than 0.7. In SA, officials found that only one third of the clinics that were inspected had sufficient medication (Consolidated Report on Inspections of Primary Health Care Delivery Sites:
Department of Health, 2010:25). The unavailability of medicines is a significant barrier to patients gaining access to much needed essential medicines in South Africa (Magadzire, Budden, Ward, Jeffery and Sanders,2014:520.).In the event of shortages or unavailable medicines,South African health facilities give the patient a date on which they are to return to the facility to check and collect their medicines if they are available at that visit which translates to additional visits to the health facility (Bateman,2013:600; Magadzire et al.,2014:521). The findings of other authors' have clearly presented the case for the importance of medication in the patient's experience. The role of medication is included in the model.
• Management Effectiveness Towards Producing Positive Outcomes
The majority of patients agree that managers play an important role in supporting effective health care with positive outcomes. The factor analysis showed that management effectiveness towards producing positive outcome is not significant to patient experience as it yielded a value less than 0.7. Whilst Kaufman and McCaughan (2013:53) "contend that leaders cannot be seen to turn a blind eye to poor practice, as this sets the pattern of behaviour for the whole team", the entire health care approach is a team driven approach and requires commitment from every team member. This statement is, not meant to detract from the importance of the leader, as he/she is an
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important member of the health team. "Managers are essential participants in improving healthcare quality, and they need to participate in ensuring that patients receive safe, efficient and equal care" (Frojd, Swenne, Rubertsson, Gunningberg and Wadensten,2011:228). Whilst the patients do agree that this is an important aspect of their experience, the latent factor analysis provides a contrasting finding to that of the respondents' perspective and to other authors in this field of study. This could be attributed to the fact that management is not solely responsible for the effective functioning of the clinic or the positive outcomes for the patient. Management Effectiveness towards producing positive outcomes is not included in the development of the conceptual model.
• Information
The majority of patients' reported that information influenced their experience of care. The factor analysis showed that the domain of patient centred care is not significant to patient experience as it yielded a value less than 0.7.The results contrast each other and the findings of other studies.
One train of thought supports the importance of providing the patient with adequate information to enhance the health service experience (Dookie and Singh,2012:67) whilst an opposing viewpoint submit that patients may suffer from information overload. This can cause patients to feel overwhelmed and inundated at the point of information reception, which may have the opposite effect to that of the desired positive experience (Jencks et al.,2009:1418). Information is not included in the development of the model.