Copyright 2005 American Medical Association. All Rights Reserved.
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To identify parents’ priorities and satisfaction in relation to
pediatric care to assess nurses’ and physicians’ ability to provide
care and treatment that fulfill parents’ needs.
Design, Setting, and Participants
The study took place in the pediatric ward of a regional hospital in
Denmark. It included 300 parents of children admitted for acute care, and
the data were collected by means of a self-administered questionnaire. After
admission, parents were asked about priorities. After discharge from the hospital,
parents were asked to report their level of satisfaction with the elements
of care they had received during their stay.
A total of 253 questionnaires were returned for the first section (a
response rate of 84%), and 170 questionnaires were returned for the second
section (response rate of 67%). The greatest gap between priorities and satisfaction
was in the waiting time related to admission, waiting time related to fulfillment
of the child’s needs, and information given about care and treatment.
Parents were most satisfied with the nurses’ behavior; however, physicians’
performance was given the highest priority score.
Parents’ priorities and assessments of inpatient pediatric care
rest heavily on the communication between physicians and parents. The present
study pointed to the need for improved and clearer communication. In addition,
the poor performance with regard to waiting time indicates that this is a
major area for improvement.
The most important outcome of pediatric care is the improvement of the
child’s health or reduction of symptoms. However, parents’ satisfaction
is associated with such central outcomes, including adherence to the therapeutic
regimen and understanding of medical information, that parents’ satisfaction
with care can be considered a good proxy variable for some important aspects
of quality of care.1 Unfortunately, until now,
parental experience with pediatric inpatient care has not been carefully described.
Study of the literature, however, identifies important problems in the quality
of care, especially regarding the information available to and communication
with parents.2- 5
In general, satisfaction is considered a key measure in care quality,
but variations from person to person in the importance of different issues
often are not included in the studies. Importance can be measured by asking
about priorities. The addition of priorities to a satisfaction theory prompts
the question, What does the patient want? Priorities are attitudes and can
be defined as the patient’s preferences or desires. They are evaluative
or affective, describing a feeling in favor or disfavor of a service.6- 8
Measuring priorities together with satisfaction gives knowledge not
only about parents’ satisfaction but also about what the issues mean
to the parents and to what degree they are evaluated as important. Therefore,
identification of parents’ priorities may be an important instrument
to improve ways of measuring care quality and may also help as a guideline
when it comes to improving health care.9 The
aims of this study were to identify parents’ priorities and assessments
of pediatric care and to assess nurses’ and physicians’ ability
to provide care and treatment that meet with parents’ needs.
Our study was a cross-sectional study in the pediatric ward of Kolding
Hospital in Denmark. It took place during the months of January and February
Parents of children aged 2 months to 15 years who were admitted for
acute care were enrolled consecutively when and if they arrived at the pediatric
ward any day between 8 AM and 10 PM and if they
were able to speak and understand Danish. The enrollment was not restricted
to diagnosis or length of stay. A total of 300 parents were enrolled.
Parents who were hospitalized with their child were given a self-administered
questionnaire divided into 2 sections. The first section was to be filled
in immediately at admission and included questions about previsit priorities.
The second section was to be filled in at discharge from the hospital, and
in this part we asked the parents to report their level of satisfaction with
the elements of care they had received during their stay. Parents who did
not return the questionnaire were contacted by telephone 3 weeks from the
day they had received it.
Based on several sources, including a systematic literature exploration
of other studies about parent satisfaction with pediatric care and adult patients’
priorities and satisfaction with medical care,5,10- 19 a
structured questionnaire was designed for this study. Items from 13 identified
studies about patient satisfaction were used. They represented 87 different
questions, and from them we selected 36 for our questionnaire. Some exploratory
interviews with parents of children in pediatric care also took place. The
criteria for selection of questions were (1) relevance to the target group
of the study, (2) use in several studies, and (3) use in exploratory interviews
in the ward. The questions reflected 6 dimensions of service quality:
Access to care and treatment (8 items)
Information and communication related to care and
treatment (10 items)
Information related to practical conditions (eg,
showing parents around the ward) (3 items)
Physicians’ behavior (5 items)
Nurses’ behavior (6 items)
Access to service (4 items)
For each item, the parents were asked to assess what they found most
important (section 1) on a 5-point Likert scale, from extremely important
to not important at all.
In section 2 of the questionnaire, filled in after discharge from the
hospital, the parents were asked to reassess the same 36 items, now for an
evaluation of care. Again the answers were arranged on a 5-point Likert scale,
this time from very satisfied to not satisfied. The questionnaire also included
items on parents’ characteristics: age, sex, education, and baseline
data.We made a pretest of the questionnaire in a pilot study that included
15 parents. Afterward, internal reliability tests analyzed if the questionnaire
was able to measure parents’ priority and satisfaction in a useful way.
Using the Cronbach α, the internal reliability of each of the 6 dimensions
of care was measured with the purpose of determining to what extent the items
in the questionnaire related to each other and of analyzing how accurate,
on average, the estimate of the true score was, as measured in a population
The Cronbach α score for the 6 dimensions ranged from.78 (physicians’
behavior) to.91 (nurses’ behavior). The scores for the sixth dimension
(access to service) ranged between.44 (satisfaction) and.50 (priority). The
distribution of responses was approximately normal.
To describe the parents’ priorities and satisfaction, the mean
score of each item was calculated using scores from 1 to 5 on the rating scale.
This pattern is illustrated in a scatterplot (Figure 1) and was analyzed by comparing the mean of the priority
score with the satisfaction score of each item. Statistical analysis was carried
out using SPSS statistical software (SPSS Inc, Chicago, Ill). Statistical
significance was set at P<.05.
Scatterplot of priority mean score
and satisfaction mean score for the 36 questions.
The purpose of the survey was explained to the parents. Anonymity was
assured in a letter handed out to parents with the questionnaire. The Danish
Scientific Ethical Committee approved the study.
A total of 253 section 1 questionnaires were returned (a response rate
of 84%), and 170 section 2 questionnaires were returned (a response rate of
67%). Table 1 lists the characteristics
of the parents.
The majority of responders saw most aspects of care as important. Table 2 indicates that the aspects valued most
in the total sample of parents were questions and information relating to
care and treatment. For example, the item “Find out what is wrong with
the child” (number 4) has a mean score of 4.6, and since the maximum
score is 5.0, it tells us that nearly all parents view this problem as their
highest priority. Other items with a high mean score are “Taking care
of the child’s pain if it is relevant” (number 8) and “Explanation
of the diagnosis/problem” (number 5). Items on practical information
such as “The nurses show you around the ward” and “The nurses
tell you about the ward procedures” were the lowest priorities, with
a mean score of 2.8 (Table 2).
As shown in Table 2, the lowest
level of satisfaction was found for items such as “Waiting time in the
ward for medical examination” (number 1; mean score, 3.0), “The
child’s need has been taken care of, without waiting too long”
(number 7), and questions related to information about and procedures in the
ward. The parents were most satisfied with the nurses’ behavior and
information given by the nurses, but items such as “Being involved in
the care and treatment” (number 14) and “The physicians are kind”
(number 19) also got a high score among parents.
The relationship between priorities and satisfaction is illustrated
in Figure 1 in a scatterplot. The vertical
axis represents the priority mean score, and the horizontal axis is the satisfaction
mean score. Items in the upper left corner demand special attention. Parents’
satisfaction with the items in this area is rather low, although these services
are given high priority (eg, “Waiting time in the ward for medical examination”
[number 1], “The child’s need has been taken care of, without
waiting too long” [number 7], and “Information about what is going
to happen over the next days” [number 10]).
Items placed in the lower left corner also have a lower satisfaction
score, but those in this area are given even lower priority, which indicates
agreement between satisfaction and priority (eg, “The nurses show you
around the ward” [number 24], “The nurses tell you about the ward
procedures”[number 26], and “The nurses inform you how to find
things in the ward” [number 25]).
The differences in nurses’ and physicians’ ability to fulfill
parents’ needs are illustrated in Figure
2. It shows 5 scatterplots of priority mean scores and satisfaction
mean scores for 5 items related to behavior.
Scatterplot of priority mean score
and satisfaction mean score according to questions about nurses’ and
For items such as understanding the information, kindness, and taking
the parents’ experiences seriously, the physicians were given the highest
priority score, indicating that from parents’ point of view, it is most
important that the physicians demonstrate this behavior. Although the result
is not significant, the satisfaction score for the same 3 items was highest
for the nurses, showing that the parents were most satisfied with the nurses’
information (P = .06), kindness (P = .06), and ability to take the parents’
experiences seriously (P = .29). Nurses’
and physicians’ ability to express warmth and care were given the same
priority score, but again parents were most satisfied with the nurses’
behavior (P = .04).
“The nurses show teaching ability” was the only item that
was given the highest priority score in relation to the nurses, although it
was not significant. Parents were also most satisfied with the nurses’
behavior according to this item (P = .04).
This study shows that medical care and treatment as well as information
about care and treatment are issues highly ranked by parents. The lowest levels
of satisfaction were reported for waiting time, information about the ward,
and information about procedures. Whereas parents were most satisfied with
the nurses’ behavior, items related to physicians were given the highest
priority, except for showing teaching ability.
The response rates of 84% and 67% were considered acceptable for answering
2 anonymous questionnaires with 80 and 84 questions.20 It
was possible to uncover some characteristics of the parents who did not reply
to section 2 of the questionnaire because 72% of the parents who did not return
this portion replied to section 1. An analysis of satisfaction scores according
to parents’ background data showed no significant difference between
the group that replied and that which did not; that is, the results were not
The questionnaires used in the study were based on information identified
in several other studies of parents’ needs, including our own exploratory
interviews with parents of children in pediatric care. The large numbers of
questions help elicit a broad perspective of patients’ priorities.21 The items reflected all dimensions of service that
may influence parents’ satisfaction, including aspects of physicians’
and nurses’ behavior and information related to practical conditions.
This means that the questionnaire can be regarded as a tool with content validity
for the evaluation of needs in pediatric wards. The 6 dimensions of quality
are very similar to the 7 dimensions used in a Swedish parent questionnaire19 developed from the Quality of Care Patient Questionnaire,22 an instrument showing good validity and reliability.
In our questionnaire, the internal reliability of the 5 measurement indexes
has been tested with the Cronbach α to be good, with an internal consistency
of more than.78 in all but 1 index. According to the parents, most of the
36 aspects of care and treatment in the pediatric ward are important. This
was expected because the aspects were selected according to their importance
The most important needs were those related to appropriate and accessible
care and treatment as well as information about care and treatment. The less
important needs were those related to service-oriented areas. These results
correspond with the results of other studies of adult patients’ priorities
in health care.23 By analyzing not only parent
satisfaction but also the relationship between priorities and satisfaction
in response to the individual questions, it is possible to highlight special
areas in need of attention.24 Apparently only
Homer et al5 have considered both frequency
and importance in their study of the quality of pediatric care; they point
out communication with parents as the area of highest priority for improvement.
The greatest gap between satisfaction and priority was in waiting time.
This result is supported by another Danish study that shows that one third
of patients are unsatisfied with waiting time.25 The
pediatric physician in attendance will often have to decide on priorities
because he or she is responsible for both inpatients and children admitted
for acute care. For the less ill patients, it often means waiting. Unfortunately,
waiting time as a factor influencing satisfaction is an understudied aspect
of health care.26 Compared with other services,
parents rated the priorities of receiving information about the ward and information
about procedures in the ward relatively low. These results are consistent
with a Finnish study of medical and surgical wards.27
Figure 1 shows that the ward generally
met the highest priorities of parents and appropriately paid less attention
to those elements of care that parents cared less about. The question is whether
this is the true picture or just an expression of the parents’ not being
able to distinguish between satisfaction and priority. Analyzing the scores
using the Spearman ρ shows that the correlation between priority score
and satisfaction score is not significant (P = .41),
indicating that there is no relationship between priority and satisfaction
and that the parents are able to distinguish between them. However, our model
still has the important limitation that when parents’ ratings are turned
into scores, it is not possible to say that a priority score of 4 results
in a satisfaction score of 4.
The differences in physicians’ and nurses’ ability to meet
parents’ needs could be explained by the uneven distribution of men
and women (52 men and 201 women) if there were a difference between men’s
and women’s priority scores and satisfaction scores for doctors’
and nurses’ behavior. However, an analysis of the results shows that
this cannot explain the differences.
As shown in other studies, contact with the physician is of great importance.28,29 Spending little time with the patients
could be one of the reasons for physicians’ not being able to fulfill
parents’ needs to the same degree as the nurses.
This study has pointed out the most important items related to pediatric
inpatient care as seen from the parents’ point of view. Our method makes
it possible to clearly distinguish between nurses’ and physicians’
ability to fulfill parents’ needs, and the results show important differences
that can lead to further investigations and to more specific quality development.
Waiting time and communication with parents emerge as the highest priorities
Correspondence: Jette Ammentorp, MHSc, Skullebjerg
Alle 33, 7000 Fredericia, Denmark (firstname.lastname@example.org).
Accepted for Publication: August 16, 2004.
Funding/Support: This study was supported by the Lundbeck fund (Valby, Denmark) and by the research committees of Fredericia Hospital (Fredericia, Denmark) and Kolding Hospital.
Acknowledgment: We thank the staff at the Kolding Hospital pediatric ward for their assistance with the study.
Ammentorp J, Mainz J, Sabroe S. Parents’ Priorities and Satisfaction With Acute Pediatric Care. Arch Pediatr Adolesc Med. 2005;159(2):127-131. doi:10.1001/archpedi.159.2.127