Developing the pediatric surgery patient satisfaction scale and assessment of its validity and reliability

Abstract

Aim of this study was to develop a patient satisfaction scale for needs and expectations of pediatric surgery patients and to propose a new measurement tool in this field. Population of study consisted of all patients between May 2018 and February 2020 at a pediatric surgery service of a university hospital in Turkey. A pool of 70 items was prepared for scale. Two items were removed in line with expert opinions and suggestions. As a result of content validity and test application, 36 items were removed, and scale was revised. Data were transferred to SPSS Statistics 23 and AMOS 22 program. After evaluating scope validity of scale, Content Validity, Structural Validity, Exploratory Factor Analysis, and finally Reliability Analysis were examined. As a result of the analyses, 32 items with eight sub-dimensions were obtained from scale. Eight-factor scale explained 60.42% of total variance. Cronbach Alpha internal consistency of scale was found to be 0.88. Item factor loads of scale were created and the reliability of scale were obtained at desired level. The scale is suitable for patients aged 6 to 18 years old.

Keywords

Pediatric surgery patients patient satisfaction satisfaction scale development validity reliability

Introduction

Satisfaction is a concept related to whether a patient’s expectations from health services are met (Berkowitz, 2016). Patient satisfaction is an important indicator of the quality and efficiency of health services and it is also one of the most important factors that determine success of a health institution (Manzoor et al., 2019). However, measurements of patient satisfaction in pediatric population have been less studied and understood compared to adult population (Blanco et al., 2020). With regard to this, it is necessary to determine the factors that affect patient satisfaction, expectations, and quality of care, especially in pediatric patients (Espinel et al., 2014). However, since it is closely related to quality of medical care and communication, it is seen that satisfaction of parents of pediatric patients is mostly used as a satisfaction measure in literature (Ali et al., 2020). It is inadequate that parents determine measure of satisfaction on behalf of children. A common belief is that children lack perception, knowledge, and experience needed to answer questions about their health and hospital experience (Bjertnaes et al., 2012). It is also assumed that children are not cognitively mature enough to reflect their health experiences deeply and this suggests that they cannot answer questionnaire questions correctly (Okan et al., 2018).

Developmental factors such as age, verbal and cognitive abilities of pediatric populations influence the assessment of patient satisfaction (Mendoza et al., 2021). Studies have demonstrated that children under age of four can express their views about hospital care, as long as questionnaires are age-appropriate (Pelander and Leino-Kilpi, 2004). Nature of patient experience data from children is related to age of child. Specifically, young children (4–6 years old) may provide short, direct answers regarding impact of hospitalization on daily activities. Middle-aged children (ages 7–11) provide answers about role of healthcare providers related to their experience of hospitalization and provide information on ways to improve hospitalization, and older children (12–20 years) provide both likes and dislikes of experience as well as hospital experience and they can also provide detailed suggestions for improvement (Lindeke et al., 2006). Thus, although the nature of data may vary with age, it is clear that children’s perspectives should be learned, as they provide unique insights about improving hospital care (Mendoza et al., 2021).

One of the important fields regarding pediatric patients is pediatric surgery. Field of pediatric surgery, children, and families have a complex healthcare service as they come into contact with various teams from different units from the preoperative period to discharge. Unique approach and different characteristics of each surgical clinic are factors that affect patient satisfaction in a positive or negative way (Espinel et al., 2014). It is important to determine which of these factors is of high priority to ensure patient satisfaction (Agency for Healthcare Research and Quality, 2004; Espinel et al., 2014). Children have many emotional stressors and excessive anxiety during their surgical experience. These stressors and excessive anxiety negatively affect the psychological and physiological health of the child (Chow et al., 2019). Also, inhibit their capacity to cope with surgery (Dave et al., 2019).The most important concerns reported by children are unknown, unpredictable, and distressing aspects of surgery and lack of information about surgery (Meletti et al., 2019). Focusing on communication, by addressing children’s desire to be directly spoken and listened to, can greatly improve patient and family-centered care experience (Wennström et al., 2008). The American Academy of Pediatrics (AAP) recommends measuring patient satisfaction and including patient and family-centered care in all areas of pediatric surgery (Committee on Hospital Care and Institute for Patient- and Family-Centered Care, 2012). However, it is stated in two literature review that there are only few tools for measuring the satisfaction of pediatric and pediatric surgery patients, and most of these tools are unconfirmed measurement tools, and there is a need for a standard measurement tool (Ali et al., 2020; Espinel et al., 2014).

Pediatric surgery patients are treated for a wide variety of disorders and diseases such as appendicitis, congenital abnormalities, and cancer. Because of complexity of these diseases and disorders in pediatric population, patients face with a variety of specialists and meet members of care team during each visit. As care providers strive to provide the best and most comprehensive care, there is always pressure to complete tasks and responsibilities on time (Espinel et al., 2014; Lu et al., 2017). Because pediatric general surgery clinic environment is multifaceted and includes a large number of team members, it is important to identify which of these factors are among the highest priorities in determining a rewarding and satisfying patient experience (Lu et al., 2017). While a systematic review has demonstrated that few studies have included children’s direct feedback on their own experiences, all studies reviewed have taken the opinions of parents to varying degrees. Therefore, studies have revealed need for hospitals to receive direct child-patient feedback (Ali et al., 2020). Defining expectations of pediatric surgery patients will contribute to the development of tools that can be used in measuring patient satisfaction.

Aim

To develop a patient satisfaction scale for needs and expectations of pediatric surgery patients and to propose a new measurement tool in this field.

Methods

Type of research, population, and sample

The aim of this study was to develop the “Pediatric Surgery Patient Satisfaction Scale” (PSPSS). This study has been carried out in inpatient clinic of a university hospital, department of pediatric surgery between May 2018 and February 2020.

The sample is recommended to consist of at least three participants per item in the scale development studies (Kyriazos, 2018; Tabachnick and Fidell, 2006). Since the draft scale consisted of 68 items in this study, it was planned to recruit 245 participants, considering the 20% loss in sampling.

Criteria for inclusion in sample group

Children between the ages of 6 and 18 who had surgery in the pediatric surgery clinic of the hospital and were planned to be discharged, who agreed to participate in the study with parental consent, and who had undergone any surgery other than day surgery, were included in the study.

Development process of “pediatric surgery patient satisfaction scale”

Development of “Pediatric Surgery Patient Satisfaction Scale” and steps followed to test its reliability and validity are explained below.

Item pool stage: Items should cover all intellectual, affective, and action-oriented elements of experiences that may be related to variable or dimension to be measured. While creating items, care should be taken to ensure that items are simple and understandable, and that an item does not have more than one judgment or thought (DeVellis, 2003). Family-centered care, nurse, doctor, environment, preoperative, intra-operative, postoperative care, and pain management dimensions, which are considered to cover patient satisfaction from all aspects, were taken into account and an item pool was created for each of these dimensions. A total of 70 items were created for scale draft. Scale is a Likert type scale and is scored between “1” and “4” (1 – Never, 2 – Sometimes, 3 – Often, 4 – Always).

Expert opinion stage: It is recommended to consult at least three experts in order to determine content validity of a scale (DeVellis, 2003). For scale draft, opinions of 15 experts were obtained, including 10 faculty members from the Department of Pediatrics Nursing, three faculty members from the Department of Pediatric Surgery, and two faculty members from the Department of Psychiatric Nursing. Draft of scale and original English version were given to experts, and they rated suitability of items between 1 and 4. (1 = not suitable at all, 4 = completely suitable). Scores were evaluated with content validity index. The items that were found to be problematic by experts were corrected in line with the suggestions, and a draft of scale consisting of a total of 68 items was created by removing two items in accordance with expert opinions.

Pilot stage:After receiving expert opinions, the scale draft was applied to 20 children who matched sample criteria for pilot stage of study in order to apply scale to 20 people who had similar characteristics to people to be measured, but were not included in sample, and scale was ready to be applied to main sample after making appropriate changes.

Validity and reliability stage

Reliability calculations: Pearson correlation analysis was used for item-total score analysis of scale and its dimensions, and unsuitable items were removed from scale according to the correlation values. Cronbach Alpha coefficient was calculated to determine internal consistency of scale and its dimensions.

Validity calculations: Exploratory factor analysis was used to determine item-factor relationship. Analysis was carried out with “principal component analysis” method, which is one of factor extraction methods.

Measures

Data were collected using the following data collection tools:

1. Socio-demographic Characteristics and Questionnaire

Questionnaire developed by researchers consists of tree items which question socio-demographic related characteristics of patients.

2. Pediatric Surgery Patient Satisfaction Scale Questionnaire

Questionnaire developed by researchers consists of 68 items questioning satisfaction of patients.

Data collection

Since children’s legal guardians are their parents, permission was obtained from both parents and children for research. Patients and parents who agreed to participate in study were informed about purpose of study and confidentiality of data before questionnaires were administered. Questionnaires were then administered, and they were asked not to write any personally identifiable information on questionnaires. Questionnaire was collected face-to-face just before discharge from children who had undergone surgery and were at discharge stage. Researcher assisted young children to fill out questionnaire.

Data analysis

In analysis of socio-demographic data; number, percentage, mean, and standard deviation from descriptive statistics were used. In data analyses, Shapiro–Wilk test to check whether data has a normal distribution, content validity index for analysis of expert opinions, Pearson correlation analysis for item-total score analysis of scale and its dimensions, Cronbach’s Alpha coefficient to determine internal consistency of scale and its dimensions, exploratory factor analysis (EFA) to determine item-factor relationship, the EFA was carried out with “principal component analysis” method, which is one of factor extraction methods, varimax vertical rotation method, which is one of the rotation methods, was used to make factors with these items more evident.

Ethics of the research

Ethics committee approval was obtained from DokuzEylul University Non-Interventional Research Ethics Committee for the research with the decision number 2017/14-15 with protocol number 3331-GOA, dated 01/06/2017, and numbered 1487. In order to carry out research, permission was obtained from University Faculty of Medicine, Department of Pediatric Surgery. Written and verbal consent was obtained from children included in the research, after purpose of study was explained.

Results

Participants’ socio-demographic characteristics

A total of 318 patients were reached; however, 13 patients refused to participate, and 28 patients filled the questionnaires incompletely. Information on some demographic characteristics of the participants is given in Table 1. Slightly over half of participants were male 166 (52%) and 152 (48%) of the pediatric surgery patients participating in study had surgery-related to the gastrointestinal system. Average age of the participants in the study was 11.6 years (SD 2.85).

Table 1.

Characteristics of children (N = 318).

Characteristics	N	%	Mean ± SD
Age (Years)
6–9	94	29.6	11.63 ± 2.85
10–14	161	50.6
≥15	63	19.8
Gender
Female	152	47.8
Male	166	52.2
Type of Surgery
Gastrointestinal system Surgery	152	47.8
Urogenital System Surgery	85	26.7
Thoracic Surgery	35	11.0
Trauma Surgery	26	8.2
Tumor Surgery	20	6.3
Total	318	100

Validity and reliability of scale

Validity of scale

Content Validity; as stated above, expert opinions were obtained for content validity of scale. Content validity indexes on item basis were between 0.99–1.00 and 0.99 for whole scale.

Structural Validity: In order to ensure construct validity of scale, exploratory factor analyses were performed.

Exploratory factor analysis results

Kaiser-Meyer-Olkin (KMO) coefficient was calculated for Exploratory Factor Analysis and the Barlett Sphericity test was used (Field, 2013). Results show that sample size is sufficient and data are suitable for factor analysis. (KMO= .87>.70; Barlett Sphericity (χ² (Standard deviation =561)) = 4561.83; p < .001).

As a result of factor analysis, it was observed that there are eight factors with an eigenvalue of above 1. In addition, it was determined that contribution of factors after eighth factor in eigenvalue-factor graphic to variance was close to each other and at a relatively low level. Considering these results, analysis was carried out by structuring scale items with eight factors. The items (nine items) below factor load cut-off point were removed from scale one by one and analysis was repeated. As a result of final analysis, 32 items remained in scale (Figure 1). Final factor structure of the Pediatric Surgery Patient Satisfaction Scale is shown in Table 2.

Figure 1.

Diagram of the item numbers according to the validity stages.

Table 2.

Factor structure of Pediatric Surgery Patient Satisfaction Scale.

Item Number	Factors^a								Eigenvalue	Variance explained (%)
Item Number	1	2	3	4	5	6	7	8	Eigenvalue	Variance explained (%)
I28	.58								9.8	28.81
I14	.57
I27	.57
I29	.57
I12	.53
I23	.52			.33
I8	.50
I38	.46
I13	.38
I61		.82							2.18	6.41
I62	.41	.63
I68		.50
I63	.31	.49	.30
I41		.48	.34
I40			.81						1.97	5.80
I26			.68
I55			.41
I7				.79					1.55	4.57
I6				.71
I5				.54
I60					.84				1.4	4.12
I58					.70
I59					.36
I57						.76			1.33	3.9
I54						.55
I51						.31
I67		.35					.48		1.21	3.55
I53							.47
I45	.36						.45	.34
I43								.64	1.11	3.25
I11			.31					.36
I44								.33

^aFactor loads below ±.30 are not shown.

First factor analysis was carried out with a total of 68 items. However, 26 items were excluded from scale after this first analysis because it was determined that item was included more than one dimension and values in factors in which it was included were less than .10. Accordingly, cut-off point for factor loadings was determined as .30 during analysis process. (Büyüköztürk, 2018; Kline, 2011). As a result of factor analysis with 32 items, it was determined that items of scale consisted of eight sub-factors with an eigenvalue greater than 1, and it was seen that they had acceptable load values (the lowest item load value was .33, the highest item load value was .84). (Table 2). Factor loads for scale items should be at least 0.30 and items below this value should be removed from scale (Jak and Cheung, 2019). The total variance of scale collected in the eight sub-factors obtained is 60.42% (Table 2). The higher total variance rates of a scale, the stronger factor structure of scale (Büyüköztürk, 2018). Factors were named “Care and Treatment Services” (n = 9), “Postoperative Care” (n = 5), “Family Centered Care” (n = 3), “Support Services” (n = 3), “Support and Care during Surgery” (n = 3), “Social Support” (n = 3), “Preoperative Care” (n = 3), and “Hospital Services” (n = 3), respectively.

Reliability analysis results

Cronbach Alpha coefficients calculated for the scale factors are given in Table 3. As a result of the research, alpha coefficients calculated for Care and Treatment Services, Postoperative Care, Family-Centered Care, Support Services, Support and Care during the Surgery, Social support, Preoperative Care, Hospital Services, and Overall scale were found to be .84; .81; .70; .75; .56; .61; .68; .55; .88, respectively (Table 3).

Table 3.

Alpha reliability coefficients of Pediatric Surgery Patient Satisfaction Scale Factors.

Factors	Number of Items	Cronbach’s Alpha
Care and Treatment Services	9	.84
Postoperative Care	5	.81
Family-Centered Care	3	.70
Support Services	3	.75
Support and Care During Surgery	3	.56
Social support	3	.61
Preoperative Care	3	.68
Hospital Services	3	.55
Overall scale	32	.88

Discussion

In this study, a valid and reliable scale was developed to measure the satisfaction of pediatric surgery patients. Results of validity and reliability analyses showed that Pediatric Surgery Patient Satisfaction Scale has an eight-factor structure. Eight-factor structure was confirmed by collected data. In addition, it was understood that reliability of each of scale factors based on internal consistency is at a sufficient level. Item-total score correlations for all items were greater than 0.30. Reliability shows how accurately scale measures the quality it should measure and how consistent the answers given to the scale items are (Morgado et al., 2018). One of the most commonly used methods to test internal consistency is calculation of the Cronbach’s alpha coefficient. It can be said that the higher the alpha coefficient, the higher the internal consistency of the scale. In the literature, it is reported that the alpha coefficient between .60–.80 confirms the reliability of the scale, and a value between .80–1.00 indicates that the scale has a high level of reliability. An alpha coefficient that is close to 1 indicates that the reliability of internal consistency is at a high level. However, alpha coefficients between .60–.80 indicate that the scale is quite reliable, and alpha coefficients between .81–1.00 shows that the scale is highly reliable (Büyüköztürk, 2018; Cortina, 1993).

Patient satisfaction is an important measure of healthcare quality as it provides information about healthcare provider’s success in meeting customers' expectations and is an important determinant of patients’ perspective (Xesfingi and Vozikis, 2016). Patient satisfaction has become a critical component of healthcare delivery as it is related to outcomes, reimbursement, and public disclosure. Therefore, it is important to assess patient satisfaction with reliable and valid measures (CAHPS Clinician & Group Survey, 2019).

Results of this study indicate that eight-factor scale can be used to measure the satisfaction of patients in pediatric surgery. Factors were named “Care and Treatment Services,” “Postoperative Care,” “Family Centered Care,” “Support Services,” “Support and Care during Surgery,” “Social Support,” “Preoperative Care,” and “Hospital Services,” respectively. When current literature is examined, most commonly used tools and sub-dimensions for pediatric patients are as follows: Children and Young People’s Inpatient and Day Case Survey -2014 (Presence of Pain, Pain Relief, Overall Experience, Involvement in Decisions, Communication on Arrival, Communication About Care and Treatment, Communication Before Operation/Procedure, Communication After Operation/Procedure, Discharge Communication, Advice on Post-Discharge Care) Children’s Revised Humane Care Scale-2019 (CRHCS) (Professional Practice, Information and Participation in Own Care, Cognition of Physical Needs, Human Resources, Pain and Apprehension Management, Interdisciplinary Collaboration (Janhunen et al., 2019), CG-CAPHS scale, (Communication with Parent, Communication with Child, Attention to Safety and Comfort, Hospital Environment, Global Rating) (Toomey et al., 2015; CAHPS Clinician & Group Survey, 2019). Another commonly used questionnaire is one published by the National Quality Board—NHS (Admission to the Hospital, Hospital and Ward, Doctors and Nurses, Facilities for Parents and Caregivers, Pain Management, Procedures, Leaving Hospital and General) (NHS Patient Survey Programme, 2020). Unlike other scales, scale developed in this study assesses experiences and satisfaction of children before, during and after surgery. Surgery is a scary event in which children can experience intense anxiety. Surgery-related physical injury, separation from parents, uncertainty, and loss of autonomy all contribute to this anxiety (Rasti et al., 2014). These anxieties of children can negatively affect their vital signs, increase their pain, and prevent compliance with healthcare providers, thus, delay recovery (Atak and Özyazıcıoglu, 2021). For this reason, children’s satisfaction or dissatisfaction with their experiences before, during and after surgery can guide health institutions and professionals to plan necessary improvement interventions.

In this study, children’s pain experiences were considered as a measure of satisfaction. Approximately 20% of children and adolescents experience pain one year after surgery, and therefore problems such as poor sleep, absenteeism in school, and decreased activity are observed. These problems can cause use of more pain medication, longer recovery, and fear of future medical care (Chow et al., 2020). In this context, it is important to assess children’s pain experiences as a measure of satisfaction. Pain-related dissatisfaction can guide healthcare professionals in developing effective pain management strategies.

Scale developed in this study assesses communication, informing and approaches of doctor, nurse, support and cleaning personnel, secretary, and operating room team. Information about surgery is usually communicated to parents and information pages for children are often missing, whereas it is clear that preoperative information and education are effective in relieving postoperative anxiety (Yi and Hanna, 2022). Children have ability to express their feelings, thoughts, and opinions and they want to receive information about their surgery directly from a specialist. This information allows them to understand in advance what to expect from surgery, thus reduces pre- and post-operative anxieties and reducing these anxieties can facilitate recovery (Hatipoglu et al., 2018). Moreover children should be given opportunity to discuss information given by their healthcare professional to enable them to individualize and understand information. This can help children gain realistic expectations about procedures and be less uncertain and anxious about what will happen (Bray et al., 2019). Another feature that the scale assesses is general opportunities offered by institution and health team such as games, meals, etc. In the literature, children between ages of 8–11 who perceive hospital environment where there are no child-friendly elements such as toys have reported lower patient satisfaction and increased tension and fear in these environments (Sjöberg et al., 2015).

The scale developed in this study is important for determining expectations of pediatric patients undergoing surgery, providing medical treatment, physician, support services, and nursing care at desired level during hospital period or after discharge.

Limitations

First limitation of the study is that taking sample in a wide age range limits results of this study. Since scale obtained may vary according to age groups, it should be investigated in future studies. This study is limited due to the small sample size and the fact that it only includes pediatric patients from a single tertiary hospital. A larger sample should be used in future studies to obtain more accurate results, as this may affect results of scale test.

Although Cronbach’s alpha for the whole scale is high, Cronbach’s alpha values of the sub-dimensions have borderline reliability. This situation should be taken into account when measuring and interpreting sub-dimensions. In this study, test-retest and parallel form reliability could not be made due to lack of a previously developed scale and change in the measured subject according to time.

Implications for practice

Scale tested in the study can be applied to all children between the ages of 6–18. Findings obtained from scale will enable pediatric surgery teams to assess service they provide. It will ensure that factors negatively affecting patient satisfaction are determined and preventive measures are taken. Thus, it will guide planning of interventions to increase quality and efficiency of service.

Conclusion

A patient satisfaction scale was developed for needs and expectations of pediatric surgery patients by examining the literature. This scale can be applied to all children aged 6–18 years who have had surgery in any surgical field. In addition, scale can be used as a criterion for evaluating quality and success of health care in field of pediatric surgery. It can be a guide in improving the quality of health care.

Supplemental Material

Supplemental Material - Developing the pediatric surgery patient satisfaction scale and assessment of its validity and reliability

Supplemental Material for Developing the pediatric surgery patient satisfaction scale and assessment of its validity and reliability by Aysun Unal, Murat Bektaş, Neriman Turan Mantar, Oğuz Ateş, and Faika Gülce Hakgüder in Journal of Child Health Care

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethical approval

ORCID iD

Aysun Unal

Supplemental Material

Supplemental material for this article is available online.

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