Patients’ Satisfaction with Services Offered by Nurses at a Selected Ideal Clinic in Ehlanzeni District, Mpumalanga Province, South Africa

Background: The patients mainly determine if the services they are offered are useful, effective, or beneficial to them. Moreover, quality health care provision is a global concern. Most importantly, although several studies have been done globally on patients’ satisfaction, however, it remains an issue for scientific investigation, especially in South Africa, as patients’ satisfaction evaluation, specifically in a primary health care setting, is still a subject under-research.


INTRODUCTION AND BACKGROUND
The provision of quality health care services is a global concern. The patients determine the quality of health care services, describing how they regard the services as useful, providers and patients should be partnered to ensure that quality care is provided [3]. According to Osiya and others, they state that a satisfied patient adheres to treatment instructions, follows the advice, maintains continuity of care, and is most likely to recommend services to others and honours the return dates to health facilities, thus ensuring health message is spread out to the world [1].
In countries abroad, such as Germany and France, patients' satisfaction survey had been made compulsory to assess the performance of health institutions whereas, in the United States of America, patients' satisfaction survey has been influential in providing evidence for policymakers to improve health care system [4]. However, in the Sub Saharan Countries, patients' satisfaction evaluation, specifically in the primary health care setting, is still an under-research subject [5]. Patients' perception of the health system had been ignored in developing countries and underdeveloped countries [6].
Almoajel and the group argued that regardless of several studies conducted abroad on patients' satisfaction, this concept remains an issue for scientific investigation [2]. Patients' satisfaction is dependent on clients' expectations being met; it is determined through the experience of care, the way they are treated when seeking help (communication), the time taken, respect and confidentiality, and the environment they are assisted in [2].
Since the conception of primary health care approach in 1978 during the Alma-Ata conference aiming to address issues of health and promoting health for all, it has been applied successfully in countries abroad, such as Cuba, whereas in Sub Saharan Africa countries, such as Zimbabwe and South Africa, it is still a challenge [7]. In 2008, when the World Health Organisation (WHO) reviewed the PHC approach following the Alma-Ata declaration, PHC was discovered and declared as very essential due to an increase in the burden of diseases [3].
In 2021, WHO observed a need for reformation by improving equity in health (universal coverage) and applying patient-centred care on service delivery [3]. PHC in South Africa started formally in 1994; despite the challenges the country has, an effort has been made to improve the quality of care in PHC settings. A new program of Ideal clinic was implemented in 2013 to improve the standard of care through setting standards of how a PHC facility should be in terms of structure and effectiveness. It is a requirement that PHC should also be evaluated to identify gaps for improvement [8]. In South Africa, limited research have been conducted on patient satisfaction, especially at the Primary Health Care (PHC) level [4].
The Health care providers are at the centre of patients' satisfaction with PHC services. In South Africa, nurses are the frontline primary health care providers. Some clinics have visiting doctors and allied professions, whereas nurses are stationed there throughout to provide care to the patients, and consult, prescribe and educate patients. Nurses are the ones that interact with patients on a daily basis in PHC settings, hence, when patients talk about the services they received in PHC facilities, they refer mostly to nurses. It was stated that when patients evaluate health care, they focus more on the interpersonal and situational components of care [5]. This included a relationship with the health provider, communication, and humanness. Hence, the importance of evaluating health care providers' services to the public has been highlighted.
In Mpumalanga, news articles have been written voicing out the views of patients regarding services offered in PHC settings. It was reported that patients showed concern about nurses' attitude, time, and lack of interest in servicing them [9]. Conversely, in the Mpumalanga news report 2016, nurses were appreciated for being sympathetic [10]. It was against this background that the study was aimed at identifying and describing the factors that contribute to patients' satisfaction with the services nurses render in PHC facilities.

The Objective of the Study
The objective of this study was to identify and describe factors that contribute to patients' satisfaction with services rendered by nurses in a PHC setting.

METHODS
A quantitative descriptive and cross-sectional research design was used to collect data from respondents in a fixedpoint post consultation with a nurse in a selected ideal clinic in the Ehlanzeni District in Mpumalanga Province, South Africa. This study was conducted to identify and describe factors contributing to patients' satisfaction with services offered by nurses. Data were collected from all adult males and females aging 18 years and above. Respondents who were willing to participate in the research were selected through a stratified random sampling, and they were given a full explanation of the purpose and objectives of the research study, and ethical considerations were thoroughly explained to the respondents so that they voluntarily consent to participate. The data collection process was started after the informed consent form was signed. The strata included in the study were as follows: Chronic care and treatment clients above 18 years attending this selected ideal clinic were 57. Antenatal care (Maternity) was 14, which included all pregnant women above 18 years of age for Antenatal care (ANC) visits in the selected ideal clinic. Patients for Minor ailments consultations above 18 years were 43.
To determine the sample size, the Raosoft sample size calculator was used [11]. Information for sample size calculation included target population (160) of the Ideal clinic daily, confidence interval of 95%, margin error at 5%, and response distribution of 50%. This gave a sample size of 114 respondents.

Data Collection
A self-developed administered questionnaire was used by reviewing relevant literature, including the Medical Interview Satisfaction Scale (MISS-21); the ideal clinic satisfaction evaluation tool. The researchers offered clarity and availability to the respondents. Questionnaires were written in English and SiSwati. The questionnaire had Section A consisting of 8 nominal socio-demographic questions, including age, gender, marital status, educational status, employment status, the reason for visiting the clinic, how often they visit the clinic, and lastly, the patient-perceived health status. Section B consisted of ordinal clinical questions, which were ranked using a 5-point Likert point score. Section B had 4 sub-topics, namely: nurse-patient relationship, consultation, competence, and general satisfaction, which makes a total number of 28 questions.

Data Analysis
The data were coded, captured, and analysed on IBM_SPSS version 26. Categorical variables were presented as percentages, whilst continuous variables were expressed as mean and standard deviation. The comparison of categorical variables was performed using Chi-Square, and a level of 0.05 was considered significant. T-test and F-test were used to test for significant differences between groups.

Reliability and Validity
The reliability was ensured by conducting a pre-test for the consistency of the questionnaire. The internal consistency of the questionnaire was determined by using Cronbach's alpha which gave a value of 0.875, denoting a good level of reliability, which is acceptable. Content validity was ensured by consulting with experts or supervisors, who are knowledgeable about the concept under study to validate the data collection instrument and thorough literature review. Thus, to ensure face validity, the researcher developed a data collection instrument from the developed and validated Medical Interview Satisfaction Scale-21 (MISS-21) and the Ideal clinic evaluation tool [12].

RESULTS
The majority of patients (33%) who participated in the study were between the ages of 18 to 29 years, and 30 to 39 years, with most being female (67%) compared to males (33%). In terms of marital status, most patients were single (66%), and 27% of the patients were married. About 42% were employed, while 34% of the patients were unemployed. Most patients visit the clinic once every month (35%) due to chronic care and collection of treatment, with the majority reporting to have a good health status (79%). There was no statistically significant difference between the mean patient satisfaction in terms of age, gender, educational status, employment status, number of clinic visits, the reason for the visit, and health status (p-value > 0.05). However, there was a statistically significant difference between the mean patient satisfaction in terms of marital status (p-value > 0.05) ( Table 1). Out of the total number of patients satisfied, those patients that will come back to the clinic was higher (100%) than in patients that were not satisfied (70%) (P-value < 0.05). Of the patients who were satisfied with nursing care, none of them reported not coming back to this clinic, whilst a few who reported that they were not satisfied reported not coming back to the clinic (30%). The total number of satisfied patients that will recommend this clinic to other people in the community was higher (100%) than in the patient that is not satisfied (67%) (P-value < 0.05). None of the patients, who were satisfied with the nursing care, reported not recommending this clinic to other people in the community ( Table 2).
The overall mean of the nurse introducing herself to the patient was 3.74, suggesting that the patients disagreed. This indicates that most of the nurses did not introduce themselves to the patients. Mean for the item, I was given a chance to suggest alternative treatment for my care was 2.45, suggesting that the responses were neutral. This means that most patients were unsure if they were given suggested alternative treatment or not for their care. The patient seemed to agree that they did not feel embarrassed when talking to the nurse, the nurse was not in a hurry when attending to them, and that they did not have any doubt about the ability of the nurse. The Spearman correlation analysis revealed that all the items are correlated with patient satisfaction (p-value < 0.05) besides two items; the nurse introduced herself to me, and the patient felt embarrassed when talking to the nurse (p-value > 0.05) ( Table 3). The following items: felt embarrassed when talking to the nurse, the nurse being in a hurry when attending to the patient and having some doubt about the ability of the nurse who treated me, had a negative impact on the patient satisfaction whereas other items had a positive impact.

DISCUSSION
This study's findings indicated that, commonly, patients are satisfied with the health care services they got from the nurses at the clinics in contrast to other findings [13]. However, the findings indicated that there was no statistically significant difference between the mean patient satisfaction in terms of age, gender, educational status, employment status, number of clinic visits, the reason for the visit, and health status [14]. In contrast to these findings, other studies found that the age, gender, and level of education of the patients significantly affected the level of satisfaction; old patients were more satisfied with the services provided [15,16]. Furthermore, there was a statistically significant difference between the mean patient satisfaction in terms of marital status, which is different from other studies [14]. This points out that the marital status of patients matters as the satisfaction results are not the same for married and single.
Inconsistent with other studies, the findings demonstrate that nurse-patient relationships have an impact on patient satisfaction [4]. It was found in another study that when healthcare professionals display compassion and empathy, patients are less anxious, thus having better health outcomes [17]. Concurrent with other studies, the results identify the conduct of nurses towards patients to be a contributory factor to satisfaction which include the following: using the language of the patient to communicate, friendliness and politeness, showing interest, and listening to the patient [18]. The results further reflect that there is a lack of effort from nurses to introduce themselves to the patient as they were wearing name tags. However, not greeting patients did not have an impact on patient satisfaction.
In support of other studies, the findings confirmed that what happens during the consultation time has a role in patient satisfaction [18]. Maintenance of privacy during the consultation, time given for consultation, giving information to patients about what could be their problem, and educating them about their condition all were found to be contributing to patients' satisfaction with the services offered. Furthermore, self-care empowerment was done through the health care providers as clients felt confident in managing their health. The ability of a client to control one's environment/health (patientcentered care) and enabling them to partake in their care plays a role in service satisfaction. Allowing patients to ask a question and the suggestion of alternative ways to their care by the nurse during consultation had an impact to the satisfaction of patients, who participated in the study. Inconsistent with the literature, the results confirmed that feeling equipped and knowing what to do to take care of oneself had an impact on service satisfaction [4]. As opposed to a qualitative study conducted in Johannesburg sub-district, which revealed that due to the challenges nurses face, such as staff shortage, they confirmed that their provision of care was based more on quantity rather than quality [19]. In support of the results, Eksteen discovered that the participants were satisfied with the service because they were informed about their problem and made aware of their current state of health status [17].
The findings indicate that nurses' abilities and knowledge are identified as factors contributing to patient satisfaction. Emotional intelligence also contributes to patients' satisfaction as the results showed that the ability of the nurse to understand what the patients say and how they feel and patients feeling understood by the nurse contributed to patients' satisfaction. The findings of this study concur with the findings of another study, which showed that the competence of health care professionals plays a significant role in increasing patients' satisfaction [20]. The results also concur with a South African study on patients' satisfaction which revealed that health care providers were competent in their job. 92% of the respondents reported that the nurses knew what was expected of them, and they know what to do to assist the clients, and this indicated that they were relieved from their distress and were even willing to come back next time [19]. Thus, it is clear that if patients are satisfied with the service offered, they will come back again for the services, and they will also refer other people to utilise these services.
Like other studies, the findings indicate that patients felt embarrassed when talking to the nurse [21 -23]. This will create a problem for patients because they will suffer in silence, whereas the nurses will not be able to understand their health needs fully. The patients will never be satisfied with the health services that they receive because they might not be relevant to their needs due to a lack of communication. The study found that the nurses are in a hurry when attending to the patient. This might be due to a shortage of nurses where you find that one nurse has to attend to a large number of patients, which will, in turn, increase their workload. It was reported that staffing of nurses will decrease the nurses' workload, decrease errors, promote nurse-patient relationships and increase patient satisfaction [24]. Therefore, it can be said that nurses attending to the patient in a hurry compromise the quality of care that the patients receive, and this will indeed lead to patients being unsatisfied with the services provided. It can also be due to the large number of people who seek health care services at primary healthcare clinics. It was also found that patients have some doubt about the ability of the nurse who treated them. Nurses must have technical skills to provide nursing care. They are further expected to offer state-of-the-art interventions or activities that are in line with nursing regulations [25]. The lack of confidence in nurses' knowledge and skills will create a negative impact on patient satisfaction in this study.

LIMITATIONS
The study was conducted at a selected ideal clinic in Ehlanzeni District Mpumalanga Province, South Africa. Therefore, the responses of professional nurses working in other clinics are not included in this study.

CONCLUSION
In conclusion, the following factors contribute to patients' satisfaction with services offered by nurses in selected ideal clinics: marital status, privacy, time, nurses conduct (friendly, polite, listening), giving information to the patients, patientcentered care (involving patients in their care, allow questions and suggesting alternative or opinions and have a say in their care which will be considered), and nurses' knowledge and abilities.

AUTHORS' CONTRIBUTIONS
NP contributed to the concept, design, and literature search, data analysis, interpretation of data, and drafting of the manuscript. MA contributed to the study concept, design, data collection and analysis, interpretation of data, drafting of the manuscript's first draft, and revision of the manuscript. TM contributed to the study concept design, and analysis, interpretation of data, and revision of the manuscript. The PM contributed to data analysis, interpretation of data, and revision of the manuscript. All the authors have read and approved the manuscript for submission.

ETHICS APPROVAL AND CONSENT TO PARTI-CIPATE
Ethical clearance was obtained from the Turfloop Research Ethics Committee (TREC/68/2018: PG), South Africa.

HUMAN AND ANIMAL RIGHTS
No Animals were used in this research. All human research procedures followed were in accordance with the ethical standards of the committee responsible for human experimentation (institutional and national), and with the Helsinki Declaration of 1975, as revised in 2013.

CONSENT FOR PUBLICATION
Informed consent was obtained from all participants.

AVAILABILITY OF DATA AND MATERIALS
Not applicable.

CONFLICTS OF INTEREST
The authors declare no potential conflicts of interest concerning the research, authorship, and publication of this article.