Abstract
Acknowledging patients' experience with the care delivered in healthcare settings is crucial in ensuring the quality of healthcare service delivery. In Ethiopia, qualitative evidence of patients’ experience with inpatient care services is limited. This study aimed to explore the experience of inpatient care service among adult patients admitted to Arba Minch General hospital, Southern Ethiopia from April 05-28, 2020. An institution-based qualitative approach was carried out among adult patients discharged from the study hospital. Thirty-one in-depth interviews using a semi-structured interview guide were conducted and audio-recorded data were transcribed verbatim and translated into English. Data were coded, sorted, and themes were developed manually based on the thematic analysis. This study showed that kindness, respecting appointments, and treatment outcomes were the positive experiences highlighted by study participants. Participants reported a lack of drinking water, unpleasant toilet hygiene, lack of bedsheets, and absence of drugs as negative experiences. Therefore, the hospital administration should work on improving the problems mentioned by the participants of this study.
Background
Usually, the skills of the health care providers and utilization of contemporary therapeutic equipment were recognized as the key determinants for advancing the quality of health service delivery (1). However, current evidence suggests the importance of integrating customers’ perspectives and feedback in improving service quality. As a part of the client's perspective, patient experience is the sum of the interaction between the healthcare institution and the client concerning the service obtained (2).
The experience of patients about the health care service focuses on the evaluation of the patient's actual objective experiences during their visits. Therefore, exploring patient experience provides input for improving service quality and making a strategic decision to meet patients’ expectations (3,4).
Patient experience is directly related to the quality of health care service delivered. However, failure to identify and utilize this feedback in the continuum of the health care delivery system can result in a negative patient experience. This, in turn, results in decreased patient loyalty to healthcare institutions, low ranking, decreased customer visits, financial instability (1,4,5), loss of customers (6–8), poor patient adherence, or compliance to medical treatments and orders and affects health care providers’ satisfaction and turnover (3,8–11).
In addition, patients’ trust in service providers has a significant impact on their experience with hospital services (12). Accordingly, low patient trust in service providers results in decreased trust and confidence among patients (9), negative client-provider relationships (8,13), and the inability of the health institution to remain financially sound (3,8–11). Therefore, recognizing and making use of patients’ perceptions and feedback about the services they utilized in health facilities is vital for improving the quality of health care service (14).
In Europe, the national health service survey report indicated that improvement in privacy, respect, and dignity of patients, and cleanliness of the hospitals had a positive relationship with patient experience (15). Similarly, in Australia, improvement in waiting time, admission and discharge process, and involvement of the patient in their treatment process are related to patient experience (16).
In Ethiopia, while the country had shown substantial progress in health sector programs achievements (17,18), providing patient-centered and quality healthcare services is at a standstill and needs further interventions. Besides, the utilization of patients’ feedback to advance the quality of care is low (28.6%) (19).
Although evidence suggests the importance of using patients’ perspectives, there were no studies conducted in Ethiopia on the experience of the patients with the service they received in hospitals. Thus, the current study aimed to assess the experience of inpatient care service among adult patients admitted to Arba Minch General hospital (AMGH), Southern Ethiopia using qualitative methods.
Methods
Study Area and Period
The study was conducted in AMGH from April 05-28, 2020. It is situated in Arbaminch Town, the capital of Gamo Zone, Southern Nation Nationality, and Peoples Regional State. The town is found about 505 km South of Addis Ababa and 275 km from Hawassa, the capital of the Southern Regional State. The hospital has 4 adult inpatient units: surgical, medical, obstetrics and gynecology, and ophthalmic units. The study population was all adult patients discharged from the admission units of the study hospital.
Sample Size Determination and Sampling Procedure
A total of 31 patients selected from all adult admission units were interviewed at the exit. Using a purposive sampling method, patients with no history of a previous admission and/or those with a duration of hospitalization of fewer than 72 h, and those who met inclusion criteria, but were seriously ill and/or unable to provide information were excluded from an in-depth interview (IDI). The selection of participants from units was stopped after data were saturated or after adding more participants from the units does not generate any new information.
Data Collection Instruments and Procedures
Data about patients’ experiences were gathered using IDI in a quiet room to minimize distractions. Ten guiding semi-structured questions were prepared based on the literature. The questions were first prepared in English and then translated into the Amharic language. The duration of the interviews was between 40 and 60 min. Moreover, the first and second authors conducted the interviews.
Data Management and Analysis
Field notes data were organized and audio recorded data were transcribed verbatim and translated by 2 different translators and compared for consistency. Finally, data coding, sorting, and themes were developed based on the thematic analysis procedure provided by Braun and Clarke (20) manually. Thematic analysis was chosen as this method was usually not tied with a particular epistemological or theoretical perspective and was flexible to manage any changes made (20,21).
Result
Participant Description
Thirty-one participants were included in the IDI. Among them, from the medical and surgical units, 14 patients (7 from each unit), 11 from the obstetrics and gynecology unit, and 6 patients from the ophthalmic unit were selected for this study based on the size of the units. Moreover, of the participants of this study, 19 were males and 12 were females. The minimum and maximum age of the participants was 27 and 48 years, respectively. Furthermore, the study participant's lowest duration of hospital stay was 3 days and 1 month was their highest duration of hospital stay. The interviews were audio-recorded by experienced voice recorders. The duration of the interviews was between 40 and 60 min.
The findings of the interviews were discussed in the following 6 themes.
Theme-1: -Experience With the Relationship and Communication of the Hospital Staff
Participants experienced that they had a good relationship and communication with the hospital staff. For instance, the majority of them stated that even though there were no direction indicators, the hospital staff told them where to go. Furthermore, they appreciated the hospital staff's kindness and prompt response to their request.
During my stay, the explanation and communication provided to me by the hospital staff were good. This is because when I ask staff, they respond to my request on time. [A 34-year-old male from the medical unit]
Nevertheless, participants expressed that the health professional's promise and communication were disappointing. Also, they highlighted that they had no such involvement in medical decisions about their health problem during their hospital stay.
…..I would not say that I had such kind of participation in terms of involving myself in medical decisions. The reason is that they decide on their own and come to me and told me that I need to do/buy these things otherwise; I do not have any participation. [A 34-year-old male from the medical unit]
Theme-2:- Experience With the Hospital Environment
Participants of this study highlighted that the hospital and ward environment was very comfortable and quiet. They appreciated the quality of the food served by the hospital, but some of them reported that they were not using hospital meal service due to fear of the admission payment increment. Participants with a previous history of admission to this hospital also highlighted that there were improvements in the cleanliness of the hospital environment.
I am very happy with the cleanliness of my room and the hospital compound but I did not use the food service because I thought that it would increase the admission fee. [A 38-year-old female from the surgical unit]
Conversely, participants highlighted the lack of cleanliness of the toilet, absence of drinking water and hand washing facilities, and lack of bedsheets as their negative experiences with the hospital environment.
Regarding the comfort of the hospital and bedrooms, it was good. But, toilet hygiene is very unpleasant. Eh, I was surprised with how mothers in labor pains withstand this unpleasant odor and stay in the labor room. [A 27-year-old female from the obstetrics and gynecology unit]
Theme-3:- Experience With Treatment and Care
Participants expressed their happiness with the treatment and care they received during their hospitalization. They also acknowledged the health professionals for the improvement of their health problems.
Now, I thank God very much for helping me. The health professionals helped me with the knowledge that God had given them and I am very happy to be saved by this treatment. [A 33-year-old female from the medical unit]
In contrast, participants reported that some of the health professionals respond in the opposite way to what they expected from them. For instance, one participant reported that when you have a concern, about treatment provided for you and ask them, they respond that “it's not my concern, or ask another health provider.” Moreover, participants reported that they were not regularly visited by health professionals. Besides this, participants also explained that there was a lack of timely response to patients’ complaints during nighttime. Additionally, they also reported lacking health professionals' respect for the appointment they give and long waiting times to get treatment for their health problems.
For example: A 38 years old female from the surgical ward who stayed in the hospital for 1 month stated:
…… However, as I tried to say at the beginning there is something uncomfortable for me in the operation room. After they admitted me, they told me that they would take skin from the other part of my body and implant it. Following this, I bought the medication they ordered but said, We’ll do it for you today-tomorrow repeatedly, they finally did the implantation after two weeks.
Another participant stated:
…. The hospital staff lacks efficiency. For example, once upon a time they told us to buy medicine and after we bought it, they came to us after three hours and I was disappointed that day. [A 36-year-old female from the medical unit]
Theme-4: Experience With the Organization of the Hospital Services
Participants expressed that the organization of the hospital service was designed in a way to provide efficient service. They also reported that the safety, reliability, and efficiency of the service organization were good. Also, participants with a previous history of admission to this hospital reported that there were considerable improvements in the organization of the services provided in this hospital.
When I look at the service structure of the hospital, I think it was designed to provide efficient service. This is because the rooms in which various medical care services are set are close to each other. Overall, I have seen great improvements in this hospital compared to the service delivered before. [A 34-year-old male from the medical unit]
Participants reported that there was an absence of most of the medications in the pharmacy. Because of that, they have been buying most of the medications outside of the hospital at a high cost. Furthermore, participants also expressed their experience with the registration room as time-consuming and the staff working in it as irritable.
The organization of the hospital's medical services was also very good, but it is challenging to get the card on time. Also, the staff in the card room do not speak out loud to talk to us properly and they get angry. [A 33-year-old male from the eye unit]
Organization of the hospital service is fine, but there is inadequate medication in the pharmacy. So, we buy most of the drugs for 120-400 birr outside of the hospital and it is good if this will be corrected. [A 38-year-old female from the surgical unit]
Theme-5: General Experience with Inpatient Care Services
Participants in the study cited regular visits by health professionals, kindness, hard work, and improved outcomes as positive experiences.
My general experience with inpatient care services given to me in this hospital is nice. Because, at the beginning when I came here, I was unconscious, but currently, I’m very happy with my current status of healthy. [A 27-year-old female from the obstetrics and gynecology unit]
Conversely, they enumerated the absence of some health professionals from their units, lack of handwashing facilities, lack of drinking water, unpleasant toilet hygiene, lack of respecting appointments given, lack of bedsheets, and absence of most of the drugs in the hospital as a negative experience they encountered. Participants also explained that financial problems and lack of support were the most commonly encountered challenges during their hospitalization.
I did not encounter such a big challenge, but since the surgery was declared free before, I did not bring enough money and for this reason, I faced a financial problem. [A 33-year-old male from the eye unit]
During my stay in this hospital, since I am a farmer I encountered a financial problem. So, I denied using the meal service of the hospital to reduce the cost of the bed. [A 38-year-old female from the surgical unit]
Theme-6:- Future Directions for Improvement of Inpatient Care Service
Participants suggested that as the hospital is a public institution there should be enough medication in the hospital regularly. Participants also highlighted that the hospital should provide enough bedsheets to the patient so that they will change them accordingly.
In the future, I think it is better if the hospital provides enough bedsheets to the admitted patients so that they change it accordingly. The other thing is we buy drinking water outside the hospital, and it is good if this problem is fixed. Besides, we buy most of the prescribed medications outside of the hospital at a price of up to 300 birrs. Since this hospital is publicly owned, it should have enough medications on the regular basis. [A 46-year-old male from the eye unit]
The participants also acknowledged the importance of regular visits and welcoming of the patient by most of the health professionals for the mental satisfaction of the patients. They also suggested that the hospital staff should respect the appointments they gave to the patients.
What I recommend to improve the inpatient care service provided by this hospital is that the staff should respect the appointment they have given for the clients. For example, they appointed me to come on Friday and after facing many challenges, they admitted me on Monday and I think it is good if this problem is corrected… [A 27 years old female from the obstetrics and gynecology unit]
Discussion
This qualitative study attempted to explore the patient experience with inpatient care service delivered to admit patients in AMGH.
The findings of this study showed that participants had a good relationship and communication with the hospital staff. This finding is supported by the studies done in the United Kingdom (UK) (22,23), Australia (10,24) and Scotland (25). This consistent finding suggests that interactions between patients and healthcare professionals are essential in any healthcare system. Moreover, participants of this study highlighted their positive experience with the way some of the health professionals respond to their concerns and explanation given to them about their health problems. Similar findings were also reported from the qualitative study done in Australia (24).
Participants stated that the hospital environment was very comfortable and quiet. This report is in agreement with the result of a qualitative study done in Norway, which reported the experience of inpatients with the environment as calm and comfortable (26).
Participants of this study had a positive experience with the treatment and care they received during their stay. This finding is supported by studies done in the UK (23) and Australia (24,27). The possible explanation for the consistency of the findings is that since these studies were based on the data collected at discharge, most patients who have been discharged from hospitals might have better treatment outcomes and are likely to have a positive experience.
Lack of information regarding their health problem and medication given to them was also reported by participants. Likewise, the study done in Iran found that participants did not get information about their health problems and/or treatment given to them (28). This similarity might imply that patients in all health settings, regardless of the health care they receive, want to be informed about their health status and treatment. Moreover, the findings reflect the desire of the patients to be involved in the decision-making process. Consistent with the finding of the studies in Scotland (25) and Norway (26), postponing the appointment given was also found as a negative experience. A possible reason for this could be patients' fear of worsening medical conditions as their appointment is postponed and this finding suggests the need to provide appropriate explanations during appointing the patients.
Moreover, this study revealed that the lack of cleanliness of toilets and bedsheets was a negative experience associated with the hospital environment. This is in line with the result of the studies in the UK (23) and Australia (24), which reported a lack of cleanliness in the facility and uncomfortable beds as negative experiences, respectively. This finding suggests that regardless of the type of care provided, making the hospital environment suitable for patient care is essential in all health systems.
Participants reported that the organization of the hospital service was good. However, they expressed their experience with the availability of medications in the hospital as disappointing. This finding is consistent with a qualitative study conducted in Burundi (29), where a lack of medicine was found as a negative patient experience. This could be due to the low socioeconomic status of developing countries which may have its own influence on the fulfillment of necessary medications. This, in turn, leads to poorer care as compared to developed countries.
The participants also encountered some challenges during their hospital stay. Accordingly, financial problems and physical support were among the main challenges reported by the participants. This finding is consistent with a study done in the United States of America (30), which found that financial challenge was the common challenge mentioned by the study participants. This finding highlights the difficulty that patients face when trying to pay for medical services which is even more challenging in developing nations where there is limited access to healthcare services.
Participants also highlighted some areas of improvement in the future. They suggested that the hospital should regularly buy enough medication. They raised the lack of bed sheets, toilet cleanliness and regular visits by health professionals, and postponing of appointments as areas to be improved in inpatient care service in the future.
Strength and Limitation
The qualitative nature of the study provides a deep understanding of the patients' experience with inpatient care service and the selection of study participants during discharge could have minimized the probability of recall bias.
However, since the study was conducted in the hospital setting, the participants might fear and provide responses supporting the hospital staff. Moreover, fatigue and tiredness associated with illness and hospitalization could have influenced the participants’ responses. Furthermore, as participants were admitted for 3 days to 1 month that might have contributed to variations in their experience with inpatient care services. However, since the sample size is relatively large and the interviews were stopped after data were saturated, the findings are not likely to be unbalanced by this factor.
Conclusions
Participants had a positive experience with the health professionals' kindness, cooperation, and treatment outcomes. Conversely, they mentioned the lack of handwashing facilities and separate drinking water, unpleasant hygiene of the toilet, lack of bedsheets, and lack of enough drugs in the hospital pharmacy as negative experiences. Therefore, the hospital administration should work on improving the problems mentioned by the participants of this study.
Footnotes
Acknowledgments
Authors thank Mekelle University, Arba Minch General Hospital, and study participants.
Author Contributions
Kebede Gemeda and Kusse Urmale conceived and designed the study, involved in data collection, and data analysis, and revision of the manuscript. Haftu Berhe and Hailemariam Berhe participated in the design of the study, and revised the final manuscript. All authors read and approved the final manuscript.
Data Availability
The datasets used and analyzed during the current study are available without restriction.
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 Consideration
Ethical clearance was obtained from Mekelle University, College of Health Sciences, institutional review board dated 21st January 2020 and numbered 1573/2020. An official letter was also received from the administration of AMGH. Moreover, written informed consent was obtained from each participant after explaining the procedures and purpose of the study.