Journal INDEX DE ENFERMERIA (digital version) ISSN 1699-5988

ISSN: 1699-5988 In English

Index de Enfermería Digital

ORIGINALS ARTICLES

User's claims, an instrument to evaluate nursing

Cayetano Fernández Sola*, José Granero Molina**
*Radiology and Radiotherapy Supervisor. Torrecardenas Hospital. Almería, Spain. **Asocciated teaching of Nursing University School. University of Almería, Spain

Mail address: Cayetano Fernández Sola. C/ Río de la Plata sn. Dúplex 31. 04120 Costacabana. Almería, España

Manuscript received by 11.11.2003
Manuscript accepted by 2.04.2004

Index de Enfermería [Index Enferm] 2004; 47:21-25 (original version in Spanish, printed issue)

How to cite this document

Fernández Sola C, Granero Molina J. User's claims, an instrument to evaluate nursing. Index de Enfermería [Index Enferm] (digital edition) 2004; 47. In </index-enfermeria/47revista/47e21-25.php> Consulted

Abstract

The survey of the health care quality through the analysis of claims is an accredited tool in the biography consulted. Although users´ assessments concerning nurses are usually positive, complaints are nevertheless increasing through different ways. Our objectives are to study both, the user's perception of our deficiencies and the professionals´ attitude with their patients.
We propose an observable evaluation through the analysis of documents (claims presented by radiology service users from January 2000 to September 2003 and reported by the nursing department, as well as the supervisor´s reports to the management of the hospital). Most of the claims denounce: delay in the appointments, lengthy periods of waiting, incorrect manners, insufficient information, bad professional praxis, lost of explorations, lack of material, etc.
We agree on the revised surveys that the claims are valid as indicators of a deficient assistance and in their systematic study to detect and to correct organisational, structural defects, etc. The changes we have embarked on will not be useful if no other changes in the relationship professional/patient take place, which starts by "knowing what they say to us".

Introduction

The survey of the health care quality through the analysis of claims, complaints and suggestions made by the users is an accredited tool in the biography consulted. Although most of the authors agree that the implementation of some more methods such as interviews, satisfaction surveys or group techniques is also important to get additional information.¹ There are a lot of quantitative studies on that issue whereas qualitative approaches are less common.

Qualitative studies are supported by Vasco Uribe²(1995), who talks us about the need for individuals who have traditionally been analized to take part in research works. Including users in this process means taking social commitment as a starting point, which does not imply lack of explanatory capacity or scientific rigor. It is just a different way of giving information for a specific purpose and with a practical use. Users's assessments make it possible to get more specific information because they are involved in a specific process, and that makes it easier for them to realize of some aspects that would never come to light otherwise.³ It is about placing the user in the middle of the system even when doing reseach in order to help him.

If we take into account users' assessments concerning work and nurses manners ,expressed either by satisfaction^1,4 surveys or by other methods which allow the patient to express his degree of satisfaction,⁵ we conclude that the assistance we provide is positively appreciated. Patients make use of different ways to express their complaints: they do it by using complaint forms or by addressing to the ombudsman or to different managers of the mass media.

In this sense, it should be highlighted how users' associations, aware of the assistance given, feel there is no parallelism between this and the information and manners of professionals.⁶A study carried out by Darriba⁷ shows professionals' assessments concerning manners and 43% of them think that professionals do not address to patients in the right way.

The aim of this work was to study the users' perception of the Torrecárdenas hospital radiology service concerning (1) deficiencies perceived by users related to structural and organizational aspects and (2) professionals' manners when dealing and communicating with patients beyond technical aspects.

In order to deal with all these objectives we carried out quantitative research so as to get information about structural and situational contexts where problems arise.⁸ When choosing the qualitative methodology we intended to achive a deeper knowledge of the professional/patient relationship and a more holistic approach to the assistance we give.⁹ That is because we think that claimers, considered to be users' interpreters, are those who better realize and describe problems because they are the ones who face those deficiencies.¹⁰

Methodology

We propose an observable evaluation through the analysis of documents, most of them relate the user's experiences in our service. In order to carry out the survey we have analyzed 55 claims presented by radiology service users of Torrecárdenas hospital from January 1st 2000 to September 30th 2003 and reported by the nursing department. Personal information has not been disclosed so as to respect the privacy of those people we have included in our research.

Those have been the stages we have followed in order to carry out the study:

Stage I: A deep reading of all claims in order to get a mental image of the whole issue and to underline basic units of analysis, so as to take information from every stage. Some parts of the speeches related to detected problems.

Stage II: Organization and reorganization of parts of the speeches in order to classify them into thematic units according to the following categorization:

-Delay in the appointments and delay concerning assistance in the emergency department. Complaints made because of lengthy periods of waiting at desk and also because of special and unjustified assistance ( not to respect the order of the appointments) are also included in that group.

-Nursing proceedings and bad professional praxis.

-Information and manners. Bad manners and lack of information are also included.

-Conditions of equipment and facilities.

-Loss of papers and personal objects.

Supervisor's reports to the management of the hospital have also been analyzed so as to get information on the professional standing of the person who attended claimers, the reasons which brought the situation about and actions taken by the service to try to solve these problems.

Stage III: Making a report by taking the results as a starting point. Explanations, interpretations, and the exact words taken from the claims have also been included in the report. They have enabled us to make a more accurate analysis about what the users have said, about the interpretations of the interviewers and also about statistics.

Stage IV: Last part was about conclusions and discussion.

We carried out a statistical analysis of the results taken from the claims and reports. People who complained where classified according to age, profession and relationship with claimers. Complaints were also classified attending to professionals and reasons that brought them about and the room where they took place.

Results

Delays. Some 56% of the claims denounce lengthy periods of waiting in different stages of the process when the user goes to the hospital for complementary proofs. Users do not think waiting lists are a big problem in our service but they have a different opinion when considering the time they have to queue at the desk or to wait in the waiting room and assistance given concerning emergency cases, either in the emergency department or in outpatient clinics.

Some of them suffer for those lengthy periods of waiting in every single step of the process: "...you have to wait for a long time to make an appointment in X-rays, then you have to wait again to enter the X-rays room and even there you have to wait again". "After being waiting for two hours to be called, I was told to lie on a stretcher and to wait for 45 minutes".

According to our working rules, appointments and X-rays takes priority so that appointment time is reserved in outpatient clinics. We explain that to our users and they accept it, but sometimes they get angry as well, above all when proofs have to be repeated because of the organization (some examinations are lost, others are not carried out in the right way, etc). "...I was told to wait and when I was supposed to enter the oncology office, surgery hours had just finished".

When equipment break down tight agendas suffer the consequences and that is happening more are more often because of the technology-centred systems.

Not to cancel the appointment even if the examination has to be delayed can be counterproductive unless we take the precaution of informing either the patient or his nurse that delay can take place for reasons beyond our control "A diabetic patient has fasted for 17 hours in order to wait for a scanner and we have just been told it is going to be put off until tomorrow".

When a patient is not seen when he is supposed to, he wants every patient to suffer the consequences of the delay and sometimes he does not understand that some changes are to be made concerning the order because of some priorities are taken into account:

"Patiens are called attending to some reasons such as if they need to urinate (ultrasound scan) or if children start crying".

The user sometimes feels some changes are made concerning the order so as to give priority to our relatives or friends. Even if it is true that those preferences reduce absenteeism, users feel upset when we do not do that discreetly or when we give explanations which may seen illogical: "They took an X-ray of my child's head, which takes priority over an arm X-ray and not all the way around". We all often use the argument that some companies benefit or give bonus to their employees, but that answer is not usually accepted: "We are not talking about electricity, nor are we talking about sales or discounts".

Information and manners (9% of the claims). Occasionally users' assessments concerning manners are negative That is the way a patient who went to the emergency department expressed himself through a long claim: "The technician pushed me against a board and shouted at me...Don't breathe! Don't move! (...) you should be with goats".

Working quickly makes it possible for us not to always evaluate the patient and his possibilities of movement in the right way. As a consequence, we ask the patient to do things he is not able to: "My mother, who uses a wheelchair, was told to get on the stretcher (...)later, a very kind nurse helped her".

According to our protocols, X-rays should be handed out to staff of the service and they cannot be delivered by hand. But a exhaustive interpretation of the rules could be a wrong idea. As an example, this patient had to have another X-ray because of a mistake we had made and he even had to stand regulation demands: "I cannot have my X-ray handed over in the X-ray department without a paper from the doctor. He said to me it was not necessary and I had to go to the X-ray department twice in order to get my X-ray".

It is true that we often work under stress, we attend appointments as well as emergency cases and explorations take more time than planned, all in all, we feel we cannot do anything else so as to prevent users from inconvenience and delay. But users might not be aware of the information we have, they do not look at it the same way we do and when they say they want to lodge a complaint we ask them in an inapropriate way: "He has told me that you can lodge as many complaints as you want, he has his back covered".

Loss (10% of the claims). Loss of examinations during the delivering process are not uncommon. Even if that frequently happens in the main office, when they are not found out there, an easy but wrong way is that of telling the user to go to the X-ray department so that either implicitly or explicitly the mistake is attributed to our service.

In any case, it should be a different person from the patient who tries to sort out the problem: " CAT is not in the office yet. In the X-ray department they say to have sent it three days ago. I go from one place to another but the proof is still missing and I have to make do with a copy of the medical report".

Losses of papers are commonplace when the radiologist asks for the medical history or previous examinations and they are not given back through the apropriate channels. Internal clients ( nurses supervisor) have made complaints because of that.

Patients should get into the rooms without personal objects such as glasses or jewellery, which should be kept by a relative or left in the wardrobe. In this case, claims are made in order to recover valuable or useful objects. "I lost a medal which had great sentimental value. I plead to have it back". "When arriving to the X-ray department, his belongings where placed inside a black bag we have never seen again".

Material and equipment (11% of the claims). The effects caused by the delay in delivery of the products could have been avoided: "We have not gone to work today but the proof could not be carried out because they did not have the right contrast. Why didn't they let us know?.

The lack of immobilization methods make it necessary for us to ask relatives to immobilize their children, saying that we get irradiated".

The father of a girl tells his bad experience in the emergency department which finished with a wrong diagnosis. In this case X-ray staff are free from responsibility. To begin with, they had to carry his daughter in their arms, owing to the lack of stretchers in the emergency department and once in the X-ray diagnosis: "they were kind but we were not given any led apron".

Furniture and equipment in bad state have caused different sort of troubles to users. A right maintenance of wards implies pointing out faults and informing about them so as to make up for them before users suffer the consequences: "My tights went torn because they got hooked on a nail of the stool".

Bad professional praxis

a)Nursing procedures. Extravasation is a potential complication when administrating intravenous contrast. When the contrast is administrated by hand, detection is easy and you can stop it, but when the process is made by automatic devices (contrast pumps) we usually detect extravasation too late.

We should never undervalue the effects "My arm had really swollen up and I was in great pain. The nurse who was seeing me told me it was not important and it would not last for long".

Cancer patients have difficult venous access. After two punctures failed we called a colleague that finally managed to do it but a Port-A-Cath could have avoided the problem: "I had three punctures and I have a Port-A-Cath".

b)Technical procedures. The implementation of new technologies that technicians do not know how to use, technical and mechanical problems concerning equipment and developing system, bad quality of images and little experienced nurses working during the summer are some of the factors that can make it necessary for a test to be repeated. Sometimes a patient has to confront some of these problems at the same time "I got irradiated six times in order to have two X-rays taken".

c)Medical procedures: we have not considered bad medical praxis as being part of out study. Although we include some claims made because of that reason and reported by the nursing department to decide whether the collaborator is somehow responsible for the claim "I have come here to get the results and here they are: concerning the scanner there is no medical report and concerning the lung biopsy there is no result because there was not tissue enough".

Claims not related to the service. As an example of claim not related to the service and reported by the nursing department, it is important to point out what a patient (who works as a clerk) says as a consequence of a demonstration held by nurses working in laboratory and radiology department. He tries to alert people by saying that in the future they will be attended by other professionals: "We are supposing that professionals(technicians) will deal with people in a worse way and they are being accused of that but it is not true".

Supervisor's reports. Supervisor's reports to the management of the hospital are a key factor when giving a final answer to the patient. The following points have been considered in the report:

-An explanation of the circumstances which may have caused the situation reported by the perbon who made the complaint.

-Steps taken or planned in order to avoid having the same situation reported again.

-Oral warnings made to the workers involved in claims concerning information and manners.

-Occasionally directors are given the names and surnames of the professionals involved in a claim. A written report has been sent to these professionals on three occasions according to their official version of the events.

-We have apologized to patients and we have also thanked them for their suggestions.

-We have also issued a denial to the patients when objective information made it clear that the situation had been exaggerated and some mistakes had been made.

Discussion

During her opening speech on the second Scientific Conference on Nursing which took place in Almería,¹¹ Magdalena Santo Tomás, associate professor of Valladolid University, spoke about her personal experience, which has something in common with the experiences our patients face. When a relative is admitted to hospital they blurt the news out just like that: "You should think who is going to stay with her (for 24 hours) because we cannot take care of her". That attitude is really similar to that one reported by our user: "someone has to immobilize the child because we get irradiated". Apart from these extreme examples, if we look at the results of the satisfaction surveys we will realize that in general users are not always as pleased as we expect.

During the same conference, Nieto Márquez, users' representative, asked for better manners. He says that even if there are a small number of users who complain, we should take their demands into account:¹² "Right and understandable information (...). The patient should understand what we are telling him, it must be something different from giving him a paper and asking him to sign it".

Good manners should be required in our service. "The patient should be more than just a number. Whe should call him by their name and we should not refer to him as ward 124 or bed 35".

"Lack of respect concerning privacy. Professionals are used to seeing people naked but that is not a common situation for patients. They may mind to go naked in front of other people different from health workers.

These three demands can be applied to our service, where patients have made complaints because of the information they were given and also because of the way they were treated (9%), although this sort of complaint is found in less proportion than in other studies. In the study carried out by Cabezalí¹⁴ 20% of the complaints were related to nursing staff bad manners ; in the study Nebot¹ carried out dissatisfaction related to manners takes a second position with 14,09% of the complaints.

Assessments concerning home visits,¹³ programs on nursing education, and offices are usually positive whereas assessments concerning assistance¹⁴ during hospitalization, outpatient clinics and department supporting diagnosis (laboratory and radiology) get worse results. Nevertheless, the results of the study carried out by Sánchez, R. and his collaborators¹⁵ show a high degree of satisfaction. An example of that is that when evaluating nursing staff of a nuclear medicine service, 95.1% of the intervieweed chose the answer "good or really good manners".

As it happens in the study carried out by Nebot,¹ suggestions are really uncommon and people do not use complaint forms to express their congratulations. Three people have used the local papers so as to sent their congratulations to the staff of the radiology service. Congratulations of this kind are mainly addessed to nurses.

When comparing our results with those of the rest of the hospital, according to a study published by Pérez Morales¹⁶ which gives us information concerning the year 1996 and 1997, we can deduce that even if our service reports a high number of claims, reasons for that are really different. During the two-year period, 18% of the claims were addressed to nursing staff because of manners. Complaints made as a consequence of delay are less common (19,33%) and the percentage representing complaints concerning bad professional praxis and nursing procedures is exactly the same.

Conclusions

The management of claims and complaints should imply something more than just inquiring and issuing reports. It should be useful for the institution and also for every single service, as an instrument to detect deficiencies concerning organization, equipment, etc. and also as an instrument to measure the quality by analysing the opinion of our users.

It is important to highlight two circumstances; on one hand, dissatisfied users are the only ones who complain. It is very unusual for users who are satisfied with the service (they represent a 80% of the users according to surveys) to write a comment to express their gratitude. On the other hand, not every single user who is dissatisfied with the service lodges a complain. But in some way, users who do it help us to take our deficiencies into account. They should be considered as the users' interpreters.

Those are some of the changes and improvements made in our service as a consequence of the users' claims:

-Purchases of material to protect users.

-Replacement of damaged furniture.

-Reorganization of timetables related to appointments concerning CAT, conventional X-ray and ultrasound scans.

-Informing the staff working in the hospitalization floors about the time of the appointments and also about everything which is going to be required.

-Organization of training activities designed to develop skills in order to improve professionals' attitude towards users of the public health care sevice.

-Including complaints made because of information given by professionals and their way of addressing to patients. It could act as a disincentive when individual bonus are shared out.

Improvements concerning facilities, timetables and periods of waiting should be accompanied by other changes in the relationship professional/patient.

A deep analysis of the problems that groups of people have to confront, makes us be aware of "daily problems which are considered to be common" and which will become consubstancial and inherent in some organizations unless we look for more explanations and background solutions.

References

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			ORIGINALS ARTICLES
			User's claims, an instrument to evaluate nursing Cayetano Fernández Sola, José Granero Molina* Radiology and Radiotherapy Supervisor. Torrecardenas Hospital. Almería, Spain. Asocciated teaching of Nursing University School. University of Almería, Spain Mail address: Cayetano Fernández Sola. C/ Río de la Plata sn. Dúplex 31. 04120 Costacabana. Almería, España Manuscript received by 11.11.2003 Manuscript accepted by 2.04.2004 Index de Enfermería* [Index Enferm] 2004; 47:21-25 (original version in Spanish, printed issue)

	How to cite this document
	Fernández Sola C, Granero Molina J. User's claims, an instrument to evaluate nursing. Index de Enfermería [Index Enferm] (digital edition) 2004; 47. In </index-enfermeria/47revista/47e21-25.php> Consulted