According to SERVQUAL model, reassurance dimension rated at 64.9% from neutral to very satisfied level of health education.
Of all the patients, 90.1% reported neutral to very satisfied levels with the way the nurses initiated dialysis, 88.3% with the way the nurses carried out doctors orders,
Figure 1. Reported levels of patient satisfaction with health education during dialysis.
85% with nurses’ administration of drugs and 84% with the way nurses responded to technical hitches during dialysis (Table 4).
Fifty-eight (38.4%) patients were very satisfied with the dressing of catheter exit site in the Renal unit.
According to SERVQUAL model of quality care, the dimension of responsiveness, in regard to response to alarms by nurses rated 72.9% by those patients who depicted neutral to satisfied to very satisfied level. This is commendable for this dimension of the model of quality care.
Out of 90 patients who responded to open-ended question, the leading dissatisfaction was by 32.2% of the patients who reported delays in connecting patients to dialysis machines (Table 5). Second leading cause of dissatisfaction by 23.3% of the patients regarded understaffing of the Renal unit by nurses. This was followed by inadequate number of dialysis machines as expressed by 22.2% of patients among other causes.
From Table 6, it is evident from the checklist that machines were seemingly enough for patients for only one day. This is represented by 10% of the overall results for the item on dialysis machines. This would probably be due to patients moving to other dialysis centres and others had defaulted from treatment that day.
Table 4. Dialysis patients’ satisfaction and perception of care during dialysis sessions.
Table 5. Patient reported causes of dissatisfaction with nursing services in the Renal unit.
Table 6. Observation checklist.
Part (b) of the checklist reveals the nurse patient ratio as poor as there were only 2 days (20%) when the ratios were somehow appropriate. This would have been attributed to new nurses or visiting students being conversant with procedures after a few days in which they could improve and boost the workload. Other items and staff were generally available as these are represented by availability for 7 days (70% availability).
From the main findings, patients’ satisfaction and perception of nursing services have been rated in terms of percentages and as scores on a Likert scale. Parametric tests such as linear regression, t-tests and ANOVA were carried out to determine possibility of demographic predictors of patient satisfaction and perception with the nursing services.
The ratings of level of patients’ satisfaction with the nursing services reflect quality of nursing services as highlighted from the literature review.
According to Reference , quality health care is the care that: fits ones’ needs and preferences, includes only the medical tests and procedures one requires, and is not affected by gender, colour and language. In addition, a quality health measure is information from a patient’s record that is converted into a rate, percentage or time.
Thus according to patients’ response on satisfaction, the level of the score reflected the quality of the nursing services.
Apart from patients’ view of quality health care, quality was also measured using SERVQUAL model which incorporates five dimensions. Three dimensions utilized in this study included responsiveness, reliability and reassurance .
Level of satisfaction and perception of patients regarding nursing services was rated on Likert scale of 1 - 5 from the matrix questions raised pertaining to nursing services.
According to Dr. Watson’s carative factor number four, the strongest tool in establishing helping-trust relationship, is the mode of communication which creates rapport and caring.
The research findings reveal 123 (81.4%) patients were satisfied with the reception they had during visits to the Renal unit. This translates to satisfaction level of 3.27 on average out of 5 on Likert scale for all 151 sampled patients. These findings are consistent with carative factor four of Dr. Watson mode communication. The manner of welcoming patients in the Renal unit created rapport that led to acceptability of nursing care services.
Reference  described patient satisfaction as a desired outcome of provided care and that quality of care was reflected by judgment of degree of satisfaction.
Reference  description is supported by the research findings in which 88 (58.3%) patients and 79 (52.3%) patients featured satisfied to very satisfied levels with post dialysis observations and advice, respectively. The two post dialysis nursing services (observations and advice) had high degree of patient satisfaction which translated into high quality care in regard to the patients.
Care of patients during dialysis was generally ranked high on the Likert scale scores, meaning, it was ranked as high quality in the face of the patients. Iniating dialysis measured 3.62, alarm attendance (3.17), nurses inquiry to physicians for corrective changes (3.38), carrying out doctors orders (3.73) and satisfaction with dialysis catheter and general wound dressing was rated at 3.81, which was the highest score on Likert scale by 76.2% of the patients. General care of patients during dialysis was of high quality as patients were very satisfied. This aspect is supported by Reference , in which quotes “Care cannot be of high quality unless the patient is satisfied”.
Nurses’ attitude rated 3.43 on Likert scale for all 151 patients on dialysis. Most patients reported neutral to satisfied level of satisfaction as regarded attitude by nurses as they performed their nursing services. Reference  indicated that nursing services and nurse attitudes strongly influence the satisfaction of the patient. Patients were concerned about humane treatment as compared with cost and convenience of care.
Nursing care was also rated by SERVQUAL model of measuring service quality but on three dimensions of reassurance, responsiveness, and reliability. Reliability of the nurse to consult a doctor on noticing abnormal finding in physical exam, rated 85.3% by all patients whose satisfaction was neutral to satisfied to very satisfied lev els. Responsiveness dimension also scored high (72.9%) in the face of the nurse responding to alarms of the dialysis machines and this response was sum up of patients with neutral to satisfied to very satisfied levels. The dimension of reassurance was applied to health education in which case 64.9% was the percentage of all patients who depicted neutral, satisfied to very satisfied level with reassurance during health education. Thus quality was apparent with the three dimensions of SERVQUAL model. This depicted that services in the Renal unit were of high quality in regard to this SERVQUAL model of quality care.
In the open ended question (non-structured), 90 patients (59.6%) of the 151 respondents stated at least one cause of their dissatisfaction with the nursing services in the Renal unit. Patients were most commonly dissatisfied with reported delays with connection to dialysis machines. 32.2% of the 90 patients mentioned delays and felt that these delays were amenable to nurses acting with urgency. This concurred with reference  findings on predictors of burnout among nurses implying similar circumstances when it comes to the factors to burnout in spite of the settings.
Dissatisfaction was expressed in understaffing of nurses and inadequate number of dialysis machines by 23.3% and 22.2% of patients, respectively.
According to results obtained from the observation checklist on staffing and accessories (items) in the Renal unit, the then nurse-patient ratio was inappropriate and there were no adequate dialysis machines. Out of 10 days of collection of data with the observation checklist, machines seemed to be adequate for 1 day (10%) as this day patient turnout was low and seemingly others had gone to other dialysis centres in Nairobi environs. The nursepatient ratio was satisfactory for 2 out of the ten days of filling the checklist and this was probably due to students who had been used to renal procedures and who eased much of the workload. The poor nurse-patient ratio and inadequate number of dialysis machines was in agreement with the responses of subjects in the open-ended questions.
As pertained to the matter of improving nursing services, 33.3% of the 90 patients (who responded to openended question on improving nursing services) felt the area that required urgent improvement was availing of more dialysis machines, followed by hiring of additional nurses (27.8% of patients). These findings on improvement were commensurate with the shortcomings expressed in the checklist. In other words, what was found as lacking from the checklist was cited blindly as a requirement for improvement of the nursing services. This meant data collection was consistent in both tools.
In a nutshell, the checklist featured optimal staffing of the general healthcare staff (apart from nurses) and adequacy of dialysis items (except dialyzing machines) as featured by higher percentages of days of availability of the items at the time of filling the observation checklist.
In summing up the findings, overall satisfaction was measured. Patients were generally satisfied with the quality of services offered by nurses in the Renal unit at Kenyatta National Hospital.
From the study’s findings, it was concluded that patients were generally satisfied with the quality of nursing services in the Renal unit as overall satisfaction was 3.39 out of 5 on the Likert scale (71.2 mean score out of 105 total score on Likert scale). This was 67.8% level of satisfaction. It was also found that patients who attended twice weekly dialysis were 72, a reflection of 47.7% of the total population. An attendance that was fair enough as it controlled the uremic syndromes and also showed the patients’ desire to come back for the same treatment a predictor for level of satisfaction. Patients reported the leading causes of dissatisfaction with nursing services as an inadequate number of dialysis machines and inappropriate nurse-patient ratio in the Renal unit. Use of the SERVQUAL model depicted nursing services in the rental unit as quality on dimensions of responsibility, reliability and reassurance.
The hospital requires to equip the Renal unit with more dialysis machines to raise the levels of patients’ perception and satisfaction with nursing services/health care services in general.
Retention and improvement of nurse staff levels are required to boost satisfaction and speed of the nursing services delivery.
I wish to extend my sincere gratitude to the Kenyatta National Hospital administration for giving me an opportunity to further my studies. Great thanks go to, The Chief Executive Officer of Kenyatta National Hospital for allowing me to conduct this research at the hospital.
Thanks to all patients attending the Renal unit of Kenyatta National, hospitals who participated in the study. I know how tasking this is especially because of the sickness, but thank you for finding time towards completing the questionnaires.
Special thanks go to my research assistants who ensured that questionnaires were distributed and returned accordingly. Finally, thanks to my statistician Mr. Phillip Ayieko for his assistance in data analysis.