Inpatient Satisfaction on Non-Pharmacological Interventions for Acute Settings: A Systematic Review

Introduction

In recent decades, healthcare provision has gone a transformative shift from the focus on condition treatment to a complex multi-component service provision that promotes patient outcomes, efficiency, and cost-effectiveness. As a result, healthcare decision makers need to examine the impact and efficiency of the delivered healthcare services, starting with quality assurance.^1,2 Patient satisfaction is one of the common indicators of healthcare quality, with a known impact on clinical outcomes, service delivery, and patient safety.² It is a constant concern for healthcare organizations and researchers across the world.³

When measuring patient satisfaction, the patient’s point of view is the key issue, as is their total experience with healthcare services.⁴ Many instruments have been developed and used to measure patient satisfaction. Ng and Luk 2019,¹ have observed that medical, nursing, physiotherapy, and occupational therapy healthcare disciplines share universal patient satisfaction attributes in their concept analysis of patient satisfaction. Among these attributes are the provider’s attitude, technical competence, accessibility, and efficacy. However, most of the developed instruments included researcher-defined parameters to assess patient satisfaction.⁵

Acute settings are facilities that provide active care within a short period of time rather than chronic care over a long period. Acute care typically treats a severe injury, an acute episode of illness, or occurs during surgery recovery.⁶ For many patients, being admitted into an acute care institution can be a stressful and dissatisfying experience, highlighting the need to monitor their satisfaction and provide interventions for improving it.

Healthcare organizations and professionals have been striving to be more proactive in improving patient satisfaction through targeted interventional approaches.⁷ Several interventions have been implemented with the aim of improving patient satisfaction. Interventions can be centered on the patient, provider, organization, or multifaceted. Interventions targeting patient satisfaction could also be pharmacological or non-pharmacological. Non-pharmacological interventions are evidence-based noninvasive services, products, or programs each serving various patients satisfaction needs.⁸ Little is understood about the effectiveness of such interventions on patient satisfaction in acute care settings specifically.

Therefore, this review aimed at systematically map and summarize the evidence of non-pharmacological interventions that were targeted at promoting patient satisfaction in inpatient acute settings. Several concepts were pre-defined for the review, including adult inpatients acute settings with a length of stay of three days or more. The review also focused only on non-pharmacological interventions.

Review Question

What non-pharmacological interventions have been used in acute settings to improve inpatient satisfaction?

Methods

Study Design

Systematic reviews have been recognized as an important research technique, as they offer a comprehensive overview and summary of the latest available evidence on a given topic.⁹ The current systematic review provides data that can be used to improve future patient satisfaction interventions. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed when conducting this systematic literature review. The PRISMA flow diagram for systematic review was followed, which includes the following phases: identification, screening, and inclusion (Figure 1).

Figure 1 PRISMA Flowchart of Search Process provides summary of the screening process and number of articles recorded at the different stages in the process. Adapted from Moher D, Liberati A, Tetzlaff J, et al. The PRISMA Group. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med. Creative Commons. Abbreviation: PRISMA, The Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Identification Phase

Search Strategy

Electronic searches of Pub-Med, EBSCO, and ScienceDirect were conducted by one author (NA) on December 12, 2022. The search terms were constructed by utilizing an adapted version of the PICO framework. PICO is an acronym that stands for population, intervention, control or comparator, and outcome.¹⁰ The current review’s search terms were aligned with PICO as follows: Adults aged 19–65 and in-patients make up the population. Intervention: non-pharmacological interventions used in acute settings that impact patient satisfaction. Given that the aim of this review was to identify and map interventions that affect patient satisfaction, the control/comparator, and outcome elements were not limited to key terms. The search contained linked indexed and free text phrases, using Boolean operators.

Key Terms

The Pub-Med search term syntaxes were inpatient AND patient satisfaction AND intervention. An advanced search was used to filter the studies to include those published in English between 2016 and 2022 on adults, aged 19 or older. The total number of studies included from PubMed search totals 135. The EBSCO search term syntax was inpatient OR hospitalization OR hospitalized patients AND patient satisfaction; it yielded128 studies. The ScienceDirect search term syntax were inpatient AND patient satisfaction AND intervention, which yielded 337 studies.

Inclusion Criteria

The review included studies published within the last 10 years. In addition, only quantitative interventional studies with experimental or quasi-experimental designs were included. The study participants were adults between the ages of 19 and 65. Moreover, studies were included if the participants were admitted to acute care settings.

Exclusion Criteria

The precise criteria of exclusion were determined in the protocol of this review. These exclusion criteria are pilot or feasibility studies; those published in languages other than English and measuring satisfaction with a specific treatment, medication, procedure, or intervention (therapeutic intervention). Studies were excluded if they have been conducted in outpatient departments or at discharge, or if they targeted specialty areas such as maternity, operation rooms, mental health wards/hospitals, or rehabilitation centers. Studies measuring satisfaction of pediatric/children, older adults, and family members and studies with qualitative, mixed methods, or non-experimental designs were also excluded. Detailed information about the reasons for rejecting the articles is presented in Table 1.

Table 1 Reasons for Rejecting the Articles

Selection Process

After the search results were imported into Covidence’s Extraction 2.0, duplicate studies were removed automatically.

Screening Phase

Titles and abstracts were screened for eligibility criteria before the full-text articles were reviewed. The full articles were screened to exclude the studies that are not relevant to the aim of the review. A total of 600 articles were identified in the initial search of the electronic databases. They were published between 2017 and December 12, 2022. Twenty-six studies were duplicated in different search engines and were removed. A total of 574 titles and abstracts were screened by three reviewers (NA, HA, and SA) against the review eligibility criteria. Five-hundred-fifty-seven articles did not meet the criteria and were excluded, leaving 17 articles to be reviewed thoroughly in full by reviewers (AA, AA, and SA). Then, six additional articles were excluded for the reasons specified in Figure 1 that shows the PRISMA flow diagram results and selection criteria.¹¹ In the end, only 11 studies were suitable for inclusion in the review.

Inclusion Phase

Data Extraction

For the purpose of data extraction, an adapted Cochrane data extraction tool was used. The tool was entered into Covedience’s Extraction 2.0. Content analysis was used in this literature review and applied to the studies that met the criteria. The contents that were extracted are: Authors and year of publication, sample and sampling techniques, interventions, study variables, and the major outcomes of the studies. Detailed information on the main components of the interventions, intervention duration, timing intervention, delivery processes, providers, and the recipients were also extracted. Two researchers (SA, AR) reviewed and extracted the data independently into a table A third author resolved any conflicting decisions (AA). Tables 2 and 3 provide detailed information on the extracted data.

Table 2 Extracted Data 1

Table 3 Extracted Data 2

Quality Appraisal

Quality appraisal was done on eligible studies to assess the quality of the studies by using two tools. The PEDro (Physiotherapy Evidence Database) critical assessment tool is a commonly used instrument for assessing the quality of randomized controlled trials (RCTs). It comprises 11 elements, each of which analyzes a different aspect of the study, such as eligibility requirements, random allocation, blinding, and follow-up.²³ Each item is rated as present (1 point) or absent (0 point), with a maximum score of 10. The 11th item is a distinct rating of the study’s external validity.

On the other hand, the JBI critical appraisal checklist for quasi-experimental studies (JBI-QE) tool was used to evaluate non-RCT studies.²⁴ The JBI-QE has nine items; their scores were used to grade the quality of each trial as high, moderate, or low. Each question requires a “yes”, “no”, or “unclear” response; in certain cases, a “not applicable” (NA) response is acceptable.²⁴ Two authors performed the appraisal (HA, NA), and a third author resolved any conflicting decisions (AA). Given that the purpose of this review was to investigate interventions seeking to improve patient satisfaction, studies were not excluded based on methodological quality. Detailed descriptions of the quality appraisal of each article are presented in Tables 4 and 5.

Table 4 Quality Appraisal for Quasi-Experimental Studies

Table 5 Quality Appraisal for Randomized Controlled Trials Studies

Results

In total, eleven studies were included in the systematic review. Out of the included studies, four used quasi-experimental (pre- and post-intervention) methods,^12–15 whereas the other seven studies were RCTs (see Tables 2 and 3 for detailed information). The results were divided into parts based on the extracted contents.

Sample/ Sampling Technique

Four studies used pre- and post-intervention methods of sampling^12–15 while five studies used intervention and control/usual care groups.^{16,18,20–22} One of the studies compared the intervention between three groups¹⁷ and another study compared the intervention between 4 groups.¹⁹ These studies were conducted in several countries, including the United States,^{12,13,17,19,20,22} Canada,^14,16 Sweden,¹⁵ Iran,¹⁸ and China.²¹ The sample sizes of the studies ranged between 25 and 2892 patients with a mean of 453 patients and a median of 183 patients.

Main Intervention Components and Delivery Process

The main intervention components are as the following: Communication skills curriculum that delivered workshop and videos;¹² and handing out factsheets containing the surgical team members’ profiles, photos, training level, and roles.¹³ A Personalized Risk Evaluation and Decision Making in Preoperative Clinical (PREDICT) assessment application was implemented to generate personalized risk predictions and personalized risk estimates, as well as anticipated benefits, while three evidence- based questions were used to encourage shared-decision-making.¹⁴ A handover technique related to the shift report combining the Australian standard operating protocol (SOP) with Situation-Background-Assessment-Recommendation (SBAR) was delivered verbally, using documents.¹⁵ Traditional consent and multimedia-based presentations of patients’ procedure was delivered by a computer-generated video.¹⁶ An inpatient electronic portal contained names and photos of care team members, while short videos on medications, allergies, diagnostic test orders and results, diet, vital signs, and weight were used to assess changes in patient activation, engagement with health information, patient satisfaction, and all-cause thirty-day hospital readmissions.¹⁷

An educational video program was made of the catheterization laboratory’s atmosphere, equipment and their procedures, and the respective health care professionals.¹⁸ A patient training and portal functionality navigator on the use of an inpatient portal to enhance satisfaction and involvement with care.¹⁹ There was an in-person introduction to the online patient portal,²⁰ and a nurse-led self-management program on Chronic Obstructive Pulmonary Disease (COPD)-related hospital admissions.²¹ A Background Affect Troubles Handling Empathic Statement (BATHE) contained four questions to elicit descriptions of patients’ current medical or non-medical situations, address psychological distress of patients, and reinforce physician–patient relationships.²²

Intervention Duration and Timing

In terms of duration, interventions were delivered once for two consecutive weeks for residence and one month for nurses,¹² prior to the intervention,¹⁶ during hospitalization,¹⁷ 24 hours before the trans-radial coronary angiography,¹⁸ 5–30 minutes,²⁰ 5 times,²¹ and once a day until discharge.²² The intervention times were a one-hour workshop for nurses and 2 hours for the residents,¹² 2 to 10 minutes,¹⁵ 2 minutes,¹⁶ 15 minutes¹⁷ 40 minutes,¹⁸ depending upon the intervention group¹⁹ at 45 minutes,²¹ and from 1 to 2 minutes less than 5 minutes.²²

Providers and Recipient of the Intervention

The interventions included in this study were provided by several groups: nurse educators and physicians¹² residents,¹³ physicians only,^14,16,22 nurses only,^15,18,21 research coordinators or trained research personnel,^17,20 and technology navigators.¹⁹ However, the recipients of these interventions were nurses and physicians in one of the studies¹² and nurses and patients in another study.¹⁵ The recipients of the rest of the studies were patients.^{13,14,16–22}

Outcome Measurement

Patient satisfaction scores were measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS).^12,19 The questions were developed by the authors and reviewed by the Johns Hopkins Hospital Family Advisory Council,¹³ the State-Trait Anxiety Inventory. For satisfaction,¹⁴ review entailed the European Organization for Research and Treatment of Cancer (EORTC) IN-PATSAT32 questionnaire,¹⁵ developed by the author.^16,20 The questions were obtained from the Telemedicine Satisfaction and Usefulness Questionnaire,¹⁷ the patient satisfaction questionnaire (PSQ),¹⁸ and the COPD Transitional Care Patient Satisfaction Questionnaire (CTCPSQ).²¹ One item at the baseline and a twenty-item survey adapted from RAND Health’s Patient Satisfaction Questionnaire-III were administered post-intervention.²²

Intervention Outcomes

All studies included in the systematic review examined patient satisfaction as an outcome variable. Most studies showed an enhancement in patient satisfaction scores in the intervention group.^{14,16,18,19,21} It increased moderately in the intervention group in one of the studies.¹² Although patient satisfaction scores in other studies increased, they were not statistically significant^13,20 or showed no statistically significant difference between the groups.^15,17,22

Discussion

The included studies examined the effectiveness of various interventions on patient satisfaction, which indicates the patient’s experience in acute care departments. The studies were conducted in different acute care wards in several countries. These studies involved various types of patients from different wards such as general surgery, internal medicine, pulmonary, vascular wards. Four studies used a pre- and post-intervention design, while seven studies were RCTs. The main intervention components vary between the studies, which reduce the generalizability of the results.

The studies conducted by Allenbaugh et al 2019¹² introduced the intervention to medicine residents and nurses while a study conducted Kullberg et al 2017¹⁵ introduced the intervention to both patients and nurses. The difference between the aforementioned studies and the other included studies is that later focused only on patients.^{13,14,16–22} The participants who completed the patient satisfaction survey in all the pre-interventions were different from those participating in the post-intervention group.

Extraneous and confounding variables affected the differences between pre- and post-intervention in the single groups while the differences affected the baseline assessment. Hence, none of the included studies controlled for the effect of those variables during the analysis phase; the studies introduced the intervention to patients only and not others health professionals. Thus, the results of the study might face the accusation of sampling or testing bias.

Different questionnaires and interventions were utilized to enhance patient satisfaction within different acute care wards of the designated hospitals. Seven studies adopted the questionnaire from previous publications while a study conducted by Hladkowicz et al 2020¹⁴ developed its questionnaire based on the Institute for Healthcare Improvement (IHI). However, the study conducted by Bowers et al 2015¹⁶ stated as a limitation of the study that the questionnaire had not been validated prior to conducting the research. Moreover, the study conducted by Stein et al 2018²⁰ and Bowers et al 2015¹⁶ did not mention that the questionnaire was developed or adapted and adopted from previous publications.

On the one hand, a study conducted by Wang et al 2019²¹ and Kullberg et al 2017¹⁵ shows a questionnaire with multiple dimensions or domains while other studies utilized a few questions to evaluate the satisfaction level; it indicates that the variable of the study was not based on proven theory. Theories were utilized in intervention studies as a guide to develop questionnaires and interventions.

Educational videos, one-on-one education, platforms, endorsement and evaluation sheets, pictures of certain staff and the words used are types of intervention that had been evaluated to ensure maximum effects on patient satisfaction. Those interventions were developed, adopted, or adapted from other studies. The studies conducted by Bowers et al, 2015¹⁶ Craig-Schapiro et al, 2018¹³ Hladkowicz et al, 2020¹⁴ Creber et al, 2018¹⁷ McAlearney et al 2022¹⁹ and Stein et al 2018²⁰ developed their interventions from different scientific sources, but those sources were not apparent in their studies. Meanwhile, studies conducted by Kullberg et al, 2017¹⁵ Oshvandi et al, 2021¹⁸ and Pace et al 2017²² adopted their intervention from Wentworth et al 2012²⁶ Ying et al 2012,²⁷ Lattuca, Benoit, et al, 2018²⁸ Joseph & Marian, 1999²⁹ Russell 2009³⁰ respectively.

Notably, the only study that adapted the intervention was conducted by Wang et al 2019.²¹ The comparison groups in intervention studies utilizing two groups differed between the included studies. All the studies utilized either routine/traditional care or a limited subset of the compared intervention. Thus, all the interventions implemented in the aforementioned studies were effective in enhancing patient satisfaction within the acute care wards of hospitals, except for five studies.

Interventions included factsheets about the team members,¹³ verbal and documented handover techniques,¹⁵ an electronic portal using information about the team members and videos of orders and results of patient diagnostic tests,¹⁷ the introduction to the online patient portal,²⁰ and BATHE techniques that introduced 4 questions to patients to elicit their current medical and non-medical situation by means of discussion between the patients and their clinicians. On the other hand, six studies showed a statistically significant difference in patient satisfaction scores between the groups.^{12,14,16,18,19,21} The non-pharmacological interventions that have been used in acute settings to improve inpatient satisfaction from this review are as follows: Communication skills curriculum,¹² a PREDICT assessment application,¹⁴ a traditional consent and a multimedia-based presentations of patient’s procedure,¹⁶ an educational video program of the catheterization laboratory’s atmosphere, equipment and their procedures, and the health care professionals,¹⁸ a patient training and portal functionality navigator on the use of an inpatient portal to enhance satisfaction and involvement with care,¹⁹ and finally, a nurse-led self-management program on COPD-related hospital admissions.²¹

On the other hand, all the included studies utilized per-protocol analysis except the study conducted by Wang et al utilized intention-to-treat. In addition, none of the included studies utilized Multivariate Analysis of Variance (MANOVA), Multivariate Analysis of Covariance (MANCOVA), or Generalized Estimation Equation (GEE) although repeated measures within the included studies, and more than two dependent variables were involved in those studies. In this regard, the probability of type two error is expected within the included studies. Moreover, the central interval was reported in studies conducted by McAlearney et al as ORs, 0.50 [95% CI, 0.29–0.85]), Hladkowicz et al as (0.8 points; 95% CI, 0.1 to 1.4; P = 0.03), while others did not. In terms of the F ratio which indicates the sustainability of variation within groups was reported in studies conducted by Bowers et al as (F=44.06, p<0001), while other studies did not. However, all the studies reported a P value which indicated the level of significance, and all the studies reported p values <0.05.

Limitations

The included studies in this systematic review used inconsistent settings, sampling techniques, and interventions. Also, a measurement and statistical variation between the studies was noticed. Therefore, a generalization of the results is not applicable because of heterogeneity. In addition, this study may include risks of study selection bias, inadequate blinding, and selective outcome reporting. To overcome such a limitation, two authors independently reviewed and extracted data from the included articles in the study. The rest of the authors reviewed the extracted data, and disputes were resolved through discussions.

Implications for Practice and Future Research

This systematic review highlights recommendations for future research. For future research, a more detailed description of the evaluated interventions might aid in their transferability and any further evaluation. Moreover, the use of established and validated patient satisfaction scales and questionnaires could improve the quality and reliability of the outcomes. By the same token, when developing a novel measurement tool for patient satisfaction, the role of theory should be considered. In addition, further studies are needed to evaluate the effectiveness of intervention among all patients in different acute care departments at the same time.

Conclusion

This study aimed at systematically reviewing the evidence on non-pharmacological interventions that can enhance patient satisfaction among inpatient acute settings. Eleven articles that met the inclusion criteria were used in the review. Regardless of the heterogeneity found in the studies, six out of the eleven included studies that used different types of intervention modules were effective in improving acute care patient satisfaction. Further studies are needed to evaluate the effectiveness of intervention among patients in different acute care departments at the same time.