Patient experiences are valuable and reflect how they perceive the care received in the healthcare system; moreover, research on this topic shows a link between patient experience and clinical outcomes (1), and allows researchers, industry professionals and policymakers to identify problems and outline areas for improvement to ensure equity in access and the availability of care services (2). Bull et al. (3) summarize that patient-reported experiences are largely consistent with terms such as “patient satisfaction” and “patient expectation,” both of which are subjective terms that may reflect judgments about the adequacy of healthcare rather than quality.
Patient experience is an important outcome measure guiding quality improvement in the healthcare setting, while the patient-centreed care movement places increasing importance on patient engagement in clinical decision-making (4). Patient experience is positively related to clinical effectiveness and patient safety (5). Patient experience—which refers to a patient’s interaction with the healthcare system—enables quality of care through effective communication, respect, dignity and emotional support (6, 7) and to capture ‘what’ happened during an episode of care and ‘how’ it happened from the patient’s perspective (3). Patient experience includes areas such as communication with staff, access to information, care received, physical and emotional support, shared decision making and consideration of the hospital environment (8). Kim et al. (7) classified patient experience factors into six categories: practice, physical needs, psychological needs, social needs, practical needs and information needs. The key factors according to service users are the functional aspects of the service (professionalism, continuity and comprehensiveness). Adams et al. (9) identified three primary drivers of patient experience: the provision of safe, timely and effective treatment; fostering human connections with caring and attentive staff; and the provision of a comfortable and healing environment. Guan et al. (19) found patient age, gender, level of education, health condition and teaching hospital to be the most frequently mentioned factors. Moreover, communication has been found to be the most significant factor of patient experience (11, 12). Klint et al. (13) found that patients sometimes reported a lack of opportunities to talk and ask questions, while also finding it difficult to formulate questions (13). Friedel et al. (14) found that age and self-perceived health status were significant positive predictors of patient experience or satisfaction in many studies. Degabriel et al. (15) showed that age, environment and route to the hospital are objective factors that can influence patient experience. Damman et al. (16) revealed that age and education were the most important case-mix adjustment factors for consumer experience. There is evidence that the hospital discharge process is an important part of the patient experience and is closely linked to patient safety issues (17). Park et al. (18) describe how patients’ quality experiences are significantly related to their interactions with staff. Roos et al. (12) point out the importance of staff actively listening, fostering an environment of mutual respect, and supporting patients’ active involvement in their healthcare decisions and plans. Communication skills, empathy and a patient-centred approach by the medical and nursing teams have a great impact on patient experience and satisfaction (15).
Patient experience surveys must elicit comparable responses across heterogeneous populations, including those that vary by education, literacy, access to technology, age, ethnicity and geographic region (19).
In Slovenia, data on patient experience with hospital care is collected once a year by the National Institute of Public Health. The data for 2021 was collected in 22 Slovenian hospitals covering five medical specialties (20). There are no in-depth multivariate analyses of the collected data in hospitals, only descriptive results are available (20), with the exception of the psychometric testing of the instrument for outpatient healthcare (21).
The first aim was to describe patients’ experience with care by nurses and doctors, with the received support and their involvement in care, and the hospital environment in the participating Slovenian hospitals. The second aim was to identify variables related to patient experience with care and the hospital rating given by patients.
A cross-sectional explorative research design with a pilot study was employed.
All public health service general hospitals in Slovenia that provide general surgical and internal medicine services (N=10) and university clinical centres (N=2) were invited to participate in the study. Eight general hospitals and two university clinical centres participated in the survey (n=10). All adult patients in internal medicine and surgical wards who were able to answer the questionnaire were invited to participate in the research during a 2-week window. The patient population and proportion of the sample was calculated based on the number of patients discharged from the participating wards within 14 days of data collection. A total of 4,958 patients discharged within the 2-week window were invited to participate; of these, 1,756 returned the questionnaire (35.42%). The number of returned questionnaires varied across hospitals and ranged from 47 to 650, while the response rate ranged from 14.5% to 61.9%.
A total of 1,748 respondents reported their gender; of these, 960 (55%) were men and 788 (45%) were women. The mean age of respondents was 60.11 years (SD=17.66). In terms of educational background, the majority had a secondary school education (n=1012; 58.6%), followed by a primary school education (n=324; 18.8%), a two-year vocational college degree (n=234; 13.6%), a bachelor’s degree (n=119; 6.9%), and a master’s degree or a PhD (n=37; 2.2%).
The instrument consisted of 27 questions, three of which were demographic questions. This instrument was used in the RN4CAST study (22); it is a slightly shortened version of the Hospital Consumer Assessment of Healthcare Providers and Systems survey (23). The item sets, using the same response scale (1-never, 2-sometimes, 3-usually, 4-always), were ‘care from nurses’ (4 items), ‘care from doctors’ (3 items), ‘the hospital environment’ (2 items), and ‘experience with the hospital’ (5 items), altogether 14 items (α=0.804). The correlation analyses showed a statistically significant positive correlation between all 14 statements, and all statements explained the variance in patients’ experience in 46.8% with three factors.
The item set ‘experience with this hospital’ included three nominal questions (1 yes, 2 no) and the item set ‘hospital discharge’ included two nominal questions. For the ‘hospital rate’, a scale ranging from 0 (worst hospital possible) to 10 (best hospital possible) was used. The question on recommendation of the hospital to friends and relatives used a four-point scale (1-definitely not, 2-probably not, 3-probably yes, 4-definitely yes). For a self-assessment of overall health, a five-point scale was used (1-excellent, 2-very good, 3-good, 4-fair, 5-poor).
The RN4CAST study translation methodology developed by Squires et al. (24) was applied. Each question and statement was thoroughly checked for understandability and substantive meaning in Slovenian. The pilot testing of the patient questionnaire involved forward and backward translations checked by a panel of experts for the relevance of each item and acceptability of translation. The pilot study was conducted in December 2019 at one general hospital where 90 patients (32.6%) from internal medicine and surgical wards returned the questionnaire. Cronbach’s alpha score was good (n=14; α=0.825).
Permission to conduct the study was obtained from the National Medical Ethics Committee (No. 0120-488/2019/6, 7 January 2020). Each hospital had two weeks for data collection. The majority of data was collected between 10 February and 7 March 2020, prior to the first major wave of the COVID-19 pandemic in Slovenia. Due to the pandemic, one hospital collected data between 8 and 20 June 2020. The questionnaires were filled out with pen and paper. Participants received help from the department coordinators if they had problems filling out the questionnaire (e.g. due to visual impairment). Coordinators were not personally involved in the treatment of the patients, to minimize the influence on the results.
Data was analysed with the statistical software SPSS 22. It was important to receive over 30 responses per hospital so that all participating hospitals could be included in the data processing. When processing the data, we always indicate the number of responses. Basic univariate, bivariate and multivariate analyses were conducted. Content validity indexing calculations were completed using Polit and Beck (25) formulas. Cronbach’s alpha and the Principal Component Analyses were used to check the reliabilities and validity of the measured scale. The mean values of the individual content strands were calculated using the derived variables from the linear regression model according to the results of the previous bivariate analysis. Statistical significance was set at the p<0.05 level.
On average, participants rated their overall health as good in 39.5% (n=683) of cases, as fair or poor in 36.8% (n=635), and as very good or excellent in 23.8% (n=411). The overall average hospital rate on a scale from 0 to 10 was 8.86 (SD=1.47; min=8.09, max=9.17; p<0.001). The hospital where the respondents were staying at the time of the survey would definitely be recommended by 1,290 (75.7%) of the respondents, probably recommended by 385 (22.5%), and probably not or definitely not by 31 (1.8%) of the respondents. The mean number of previous hospitalisations was 4.47 (SD=9.39). Self-assessment of the average number of days respondents expected to spend in the hospital was 2.37 (n=1,468; SD=4.268).
On average, 79.3% of respondents stated that they always received adequate ‘care from nurses’ in relation to the variables measured. For the variable ‘care from doctors’, this proportion was 80.9%. On average, 66% of respondents rated ‘the hospital environment’ as always adequate. The average ‘support received and patient involvement’ score was 70.18%. The lowest score was achieved in explaining the side effects of medications (48.6%), followed by pain management (67%) (Table 1). The mean value of categorical variables for patient experience (n=14) (Table 1) was 3.67 (SD=0.32).
Descriptive results for the categorical variables of patient experience (n=14) in percent (%).
| Care from nurses | n | Never, sometimes % | Usually % | Always % |
|---|---|---|---|---|
| Items: During this hospital stay, | ||||
| how often did nurses treat you with courtesy and respect? | 1749 | 1.5 | 14.1 | 84.4 |
| how often did nurses listen carefully to you? | 1745 | 2.8 | 21.1 | 76.1 |
| how often did nurses explain things in a way you could understand? | 1744 | 4.2 | 22.4 | 73.5 |
| after you called for assistance, how often did you get help as soon as you wanted it? | 1652 | 3.5 | 13.3 | 83.2 |
| Care from doctors | n | Never, sometimes % | Usually % | Always % |
| Items: During this hospital stay, | ||||
| how often did doctors treat you with courtesy and respect? | 1748 | 1.7 | 12.0 | 86.4 |
| how often did doctors listen carefully to you? | 1746 | 3.2 | 16.4 | 80.4 |
| how often did doctors explain things in a way you could understand? | 1740 | 4.5 | 19.4 | 76.0 |
| Hospital environment | n | Never, sometimes % | Usually % | Always % |
| Items: During this hospital stay, | ||||
| how often were your room and bathroom kept clean? | 1725 | 2.4 | 16.9 | 80.7 |
| how often was the area around your room quiet at night? | 1725 | 8.8 | 39.7 | 51.3 |
| Support received and patient involvement | n | Never, sometimes % | Usually % | Always % |
| Items: During this hospital stay, | ||||
| how often did you get help in getting to the bathroom or in using a bedpan as soon as you wanted? | 784 | 9.4 | 10.6 | 80.1 |
| how often was your pain well controlled? | 1282 | 4.0 | 29.0 | 67.0 |
| how often did the hospital staff do everything they could to help you with your pain? | 1286 | 2.0 | 13.8 | 84.2 |
| before giving you any new medicine, how often did hospital staff tell you what the medicine was for? | 1033 | 10.0 | 19.1 | 71.0 |
| before giving you any new medicine, how often did hospital staff describe possible side effects in a way you could understand? | 1012 | 27.6 | 23.8 | 48.6 |
Note: n - Number of answers
Table 2 shows significant differences by hospital and age in most of the variables studied, with the hospital score ranging from 8.09 to 9.17 and recommendation of hospital from 3.47 to 3.87. Gender differences were only established for two variables (overall health, hospital rate). Women rated the hospital significantly higher (M=8.97; SD=1.377) compared to men, and they also rated their overall health better (M=3.27; SD=1.015). Educational background only influenced two variables.
Results of categorical and continuous variables by demographic data and hospitals.
| Variables (scale) | M (SD) | Across hospitals P | Gender P | Education P | Age P |
|---|---|---|---|---|---|
| Care from nurses (cat 1-4) | 3.76 (0.374) | 0.030 | 0.289 | 0.520 | 0.001 |
| Care from doctors (cat 1-4) | 3.77 (0.414) | 0.008 | 0.093 | 0.122 | 0.006 |
| Hospital environment (cat 1-4) | 3.62 (0.461) | <0.001 | 0.246 | 0.057 | <0.001 |
| Support received and patient involvement (cat 1-4) | 3.56 (0.462) | 0.080 | 0.270 | 0.627 | 0.726 |
| Recommendation of hospital (cat 1-4) | 3.74 (0.506) | <0.001 | 0.876 | 0.849 | 0.001 |
| Hospital rate (con 0-10) | 8.86 (1.471) | 0.001 | 0.008 | 0.105 | 0.010 |
| Overall health rate (cat 1-5) | 3.15 (1.050) | <0.001 | <0.001 | <0.001 | <0.001 |
| Expected days in hospital (con) | 2.37 (4.268) | 0.038 | 0.236 | 0.020 | 0.001 |
| Previous hospitalisations (con) | 4.47 (9.391) | 0.006 | 0.402 | 0.979 | <0.001 |
Note: M - Mean of categorical or continuous variable; cat - Categorical variable; con - Continuous variable; SD - Standard deviation, p - P-value
Differences between hospitals were established for all variables, with more than 50% of patients requiring assistance to use the bathroom in three hospitals and less than 40% in other hospitals. Women needed significantly more help in using the bathroom (55.1%), required more analgesics (78.5%), were given more new medications (60.8%), and received less oral (66.8%) and written (58.4%) information about post-discharge care. Although educational background would seem important for preparing the patient for discharge (oral and written information), this was not confirmed by the regression model (Table 3).
Descriptive and bivariate results of dichotomous variables
| Items: During this hospital stay, | n | YES (%) | NO (%) | Between hospitals | Gender (P) | Education (P) | Age (P) |
|---|---|---|---|---|---|---|---|
| did you need help from nurses or other hospital staff in getting to the bathroom or in using a bedpan? | 1654 | 752 (45.5%) | 902 (54.5%) | <0.001 | <0.001 | 0.516 | <0.001 |
| did you need medicine for pain? | 1664 | 1221 (73.4%) | 443 (26.6%) | <0.001 | 0.004 | 0.997 | <0.001 |
| were you given any medicine that you had not taken before? | 1614 | 955 (59.2%) | 656 (40.8%) | 0.009 | 0.308 | 0.866 | 0.545 |
| did nurses or other hospital staff talk with you about your care after you leave the hospital? | 1635 | 1230 (75.2%) | 405 (24.8%) | <0.001 | 0.428 | <0.001 | 0.003 |
| did you receive information in writing about what symptoms or health problems to look out for after you leave the hospital? | 1564 | 1070 (68.4%) | 494 (31.7%) | <0.001 | 0.901 | 0.002 | 0.131 |
Note: n - Number of answers
Table 4 shows the associations between the variables studied; the statistically significant ones were used in the linear regression models (Table 5).
Associations between research variables.
| Variables | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | |
|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 Care from nurses | 1 | ||||||||||
| 2 Care from doctors | 0.552** | 1 | |||||||||
| 3 Hospital environment | 0.302** | 0.219** | 1 | ||||||||
| 4 Support received and patient involvement | 0.480** | 0.423** | 0.378** | 1 | |||||||
| 5 Recommendation of hospital | 0.340** | 0.357** | 0.249** | 0.297** | 1 | ||||||
| 6 Hospital rate | 0.384** | 0.370** | 0.300** | 0.390** | 0.539** | 1 | |||||
| 7 Overall health rate | -0.185** | -0.180** | -0.071** | -0.175** | -0.153** | -0.159** | 1 | ||||
| 8 Expected days in hospital | -0.137** | -0.088** | -0.050 | -0.058 | -0.018 | -0.021 | 0.068* | 1 | |||
| 9 Age | -0.084** | -0.067** | 0.100** | 0.024 | 0.080** | 0.063* | 0.272** | 0.115** | 1 | ||
| 10 Previous hospitalisations | -0.014 | -0.029 | -0.024 | -0.036 | -0.014 | -0.040 | 0.104** | 0.052 | 0.095** | 1 | |
| Variables: | Written information about discharge P | Talk about discharge P | New medicine P | Medicinepain P | Helpbathroom P | ||||||
| Care from nurses | <0.001 | <0.001 | 0.643 | 0.534 | 0.083 | ||||||
| Care from doctors | <0.001 | <0.001 | 0.720 | 0.995 | 0.273 | ||||||
| Hospital environment | 0.001 | <0.001 | 0.042 | 0.341 | 0.479 | ||||||
| Support received and patient involvement | <0.001 | <0.001 | 0,361 | 0.369 | 0.262 | ||||||
| Recommendation of hospital | <0.001 | <0.001 | 0.669 | 0.888 | 0.084 | ||||||
| Hospital rate | <0.001 | <0.001 | 0.138 | 0.572 | 0.054 | ||||||
| Overall health rate | <0.001 | <0.001 | 0.027 | 0.038 | 0.168 | ||||||
| Expected days in hospital | 0.035 | <0.001 | 0.049 | 0.091 | 0.031 | ||||||
| Previous hospitalisations | 0.835 | 0.413 | 0.084 | 0.824 | 0.832 | ||||||
Note: M - Mean (four-point scale), SD - Standard dev’ation, p - P-value
** Correlation is significant at the 0.01 level (2-tailed)
Linear regression models of independent and dependent variables.
| Independent variables (types) | Model 1: Patients’ experience with care (R2=I8%) | |
|---|---|---|
| ß | p | |
| Previous hospitalisations (continuous) | 0.045 | 0.399 |
| Overall health rate (ordinal) | 0.267 | <0.001 |
| More days in hospital (continuous) | -0.029 | 0.576 |
| Hospitals (discrete) | -0.096 | 0.066 |
| Help from nurses getting to bathroom (nominal NO) | -0.029 | 0.576 |
| Medicine for pain (nominal NO) | -0.029 | 0.582 |
| Get new medicine (nominal NO) | 0.013 | 0.803 |
| Talk about care after discharge from hospital (nominal NO) | -0.175 | 0.004 |
| Get written information (symptoms, health problems) after leaving the hospital (nominal NO) | -0.200 | 0.001 |
| Education (ordinal) | -0.065 | 0.219 |
| Gender (nominal Women) | 0.034 | 0.513 |
| Age (continuous) | 0.026 | 0.634 |
| Independent variables (types) | Model 2: Hospital rate (R2=30.4%) | |
| ß | p | |
| Patients’ experience with care (ordinal | 0.576 | <0.001 |
| Overall health rate (ordinal) | -0.066 | 0.163 |
| Education (ordinal) | -0.019 | 0.664 |
| Gender (nominal Women) | 0.043 | 0.331 |
| Age (continuous) | 0.132 | 0.004 |
| Hospitals (discrete) | 0.032 | 0.464 |
| Help from nurses getting to bathroom (nominal NO) | -0.004 | 0.937 |
| Medicine for pain (nominal NO) | -0.039 | 0.430 |
| Talk about care after discharge from hospital (nominal NO) | 0.029 | 0.550 |
| Get written information (symptoms, health problems) after leaving the hospital (nominal NO) | -0.044 | 0.373 |
| New medicine was explained (ordinal) | -0.242 | <0.001 |
| Side effects of new medicine were explained (ordinal) | 0.118 | 0.056 |
Note: R2=Adjusted R-Squared, ß=Standard regression coefficient, p=P-value
The regression Model 1 “Patients’ experience with care” which summarizes 14 statements from Table 1, was explained in 18% by “patients’ general health status” (-0.267), “provision of written and oral information” (-0.200), and finally “talking to patients about discharge” (-0.175) The regression Model 2 “Hospital rate” was explained in 30.4 % by “patients’ experience with care” (0.576), “new medication was explained” (-0.242), and “patient age” (0.132) (Table 5).
Our research findings provide some encouraging information and reveal areas that require immediate action. Generally, the results of our study can be compared to previous studies, at least in some variables (8, 10, 14–17).
The patients who completed the questionnaire had an average of 4.5 previous hospital stays. As many as three quarters of those surveyed would recommend the hospital to other patients, giving it 8.9 out of a possible 10 points. Appropriateness of the care provided by the nursing staff and doctors was reported by 80% of patients, a figure comparable to other studies in Slovenia (20) and abroad (5,7–8, 15, 26). Furthermore, descriptive analysis revealed that information about the side effects of newly prescribed medication and pain control was rated poorly, which is important considering that three-quarters of participants reported needing pain medication and that 60% of participants had received new medication. Communication with patients about their treatment and different aspects of care has been shown to be the most important factor in measuring patient experience (11–12), followed by adequate preparation for discharge, as a quarter of participants did not receive discharge instructions and one third did not receive written discharge instructions on how to monitor symptoms and potential health problems depending on the reason for hospitalisation. The importance of comprehensive relief has also been recognised in other studies (17, 27).
Our descriptive results were compared with the results of the national survey (20), where the response rate was low, although other authors also face this problem (27). In terms of patients’ experience of care from nurses and physicians, involvement in care, hospital environment and average rating of the hospital, our results are comparable (20). Our study showed significantly poorer results in the implementation of verbal and written discharge information, information about a new medication and a significantly higher noise level on the hospital ward. In terms of the instrument used (23), the Centers for Medicare & Medicaid Services estimate that only 25% of eligible discharge patients will respond, so there is great potential for non-response bias (27, 30).
The two regression models provided important information on how to improve work with patients in Slovenian hospitals. All independent variables were significantly related to the dependent variables in bivariate analyses and could be potential indicators of improvements; they were also found to be important in other studies (5, 8, 10, 14–17, 28) but at the level of multivariate analyses, only six variables were significant in our study. Patient experience can be explained in our model by overall health status (5, 8, 10), receipt of written and oral information about symptoms and potential health problems post-discharge, and written information provided at discharge (5, 7, 9, 10, 15, 17, 27, 29). Other researchers also reported that patient health status self-assessment and comprehensive preparation with discussions and written information for discharge had an effect on patient experience ratings (10, 14, 27). For patients’ hospital rating, our study revealed that the most important factors were patients’ experience with inpatient care (5), followed by an explanation of new medication during the care process, and patient age (10, 14–16).
Patients’ experiences are becoming increasingly important in the context of quality assurance, but the measurement of these parameters is accompanied by several disadvantages, such as poor cross-country comparability and methodological problems. Schroeder et al. (31) recommended paying more attention to the patient’s emotional and psychosocial state, employment status, family and other factors. Such a holistic approach was not adopted in our study and also not in the national survey of patient experience (20). Improvements and holistic data capture are needed to make the measurement of patient experience a greater contribution to the improvement and efficiency of health systems.
The research results are influenced by the fact that the answers come from those who were able to complete the questionnaire. A higher response rate would be desirable, but it is comparable to the a national patient survey (20, 21). The personal administration of surveys in paper form led to lower response rates than surveys sent by post (29). Patients who were asked to participate in a survey by clinic staff at the point of care gave more positive responses than patients who responded in other ways (32). We cannot be sure that in some cases healthcare professionals were not involved. We believe that a five-point scale would yield more reliable results. The results are limited to answers provided by patients in selected areas and cannot be generaliszed to all hospital wards in Slovenia. It is possible that patients had some reservations or have been overly positive or negative. The cultural environment may play an important role—it could be difficult for patients to be critical towards the healthcare which they had to wait an extremely long time to receive. The translation of the instrument into Slovenian, even though done rigorously, is a limitation as context can vary due to different understanding of linguistic and cultural differences.
The importance of patient experience with healthcare provision in Slovenia remains researched but insufficiently substantiated. At first glance, the hospital rates are good, but the results of individual variables reveal that tasks connected to comprehensive preparation of patients for healthcare treatment with communication and health education, and appropriate discharge, remain only partially completed. Improvements and holistic data capture are needed to make the measurement of patient experience a greater contribution to the improvement and efficiency of hospital care.