A Gap Analysis of Perception and Expectations of Patients for the Nursing Service in a Tertiary Hospital in the Maldives

The items of nursing services in SERVQUAL scale that scored the largest mean difference between expectations and perceptions were “nurses get adequate support from the hospital to perform their services well” (-0.50) with P =.000, followed by “nurses provided nursing services using up-to-date equipment” (-0.38) with p = .000. The smallest gap scores, which represent the smallest difference between patients expectations and perceptions were for item “nurses were always willing to help me” (0.05), followed by “nurses understood what my needs were” (0.11) (Table 6).

 

Table 6. The 5 largest and smallest gap scores for each aspect of nursing care (n = 282)

Aspect of care	Service gap score (P-E)	t (p)
The 5 largest gap scores
Nurses get adequate support from the hospital to perform their services well	-0.50	-9.610	(.000)
Nurses provided nursing services using up-to-date equipment	-0.38	-7.583	(.000)
I received nursing service in a setting where physical facilities are visually appealing	-0.30	-6.298	(.000)
Nurses were sensitive to individual differences among patients	-0.24	-6.285	(.000)
Nurses served me with politeness	-0.23	-1.583	(.115)
The 5 smallest gap scores
Nurses always respond to my requests promptly	0.47	7.481	(.000)
Nurses told me exactly when nursing services will be performed	0.29	3.261	(.001)
Nurses offered nursing services at times convenient for me	0.19	3.307	(.001)
Nurses understood what my needs were	0.11	1.843	(0.66)
Nurses were always willing to help me	0.05	0.894	(.372)

 

DISCUSSION

The result of this study showed that patients’ highest expected dimension from nursing service quality and patients’ highest perceived performance dimension from nursing service quality was Reliability. This implies that reliability as the most important of the five dimensions of service quality. The potential reason Reliability was rated as the most important aspect could be due to patients relying upon nursing staff for their skillful nursing care, assistance in their recovery and for reassurance.  According to Parasuraman et al. (1988), reliability involves the service providers’ ability to provide the promised service dependably and accurately. The result also indicate that in order to receive quality nursing services, patients expected not only competent technical skills from nurses but also for nurses to offer them psychological wellbeing in the form of being concerned about their problems, being supportive and encouraging. In a study conducted by Duggirala, Rajendran and Anantharaman (2008), nurses’ competency in practice and their professional quality were found to be important to patients. The finding of Reliability as patients’ highest expected dimension and highest perceived performance dimension from nursing service quality was similar with the study conducted by Lee & Yom (2007) and Nashrath, Akkadechanunt, & Chontawan (2011). Moreover, result of this study is consistent with the study by Chou, Chen, Woodard, and Yen (2005) which used SERVQUAL to evaluate quality of nursing service in Taiwan, which showed Reliability was significant in predicting overall satisfaction with nursing care and intent to return to the hospital.

On the other hand, patients gave the lowest rating to Responsiveness dimension from nursing service quality expectation. A possible explanation for this finding could be that 65.6% participants of this study having never had a previous admission to this hospital, thus making it their first contact with nurses. Additionally, this finding is supported by the fact that the hospital permits family members to stay with the patients all times throughout the hospitalization period. Thus, having family members to help the patients, to assist them in performing activities of daily living such as bathing, feeding and to take care of the personal needs can reduce patients expectations from nurses (Nashrath, Akkadechanunt, & Chontawan, 2011). Patients desire to rely mostly on their family members, could have resulted patients to rate Responsiveness as the least expected dimension from nursing service quality expectation. This finding was consistent with study result of Nashrath, Akkadechanunt, and Chontawan (2011), which was done in Maldives but in a different setting.

The findings revealed that Tangibility was patients’ lowest perceived performance dimension from nursing service quality. This indicated patients did not perceive that nursing services could always be provided in an environment which has physical structure such as appealing physical facilities, equipment and adequate appearance of employees. To achieve high standard in the competitive advantage in service quality, medical equipment needs to be up-to-date and renewed, maintain good appearance of physical facilities and portray professional and neat appearance by staff. Similar to this finding, nursing service quality as perceived by Korean patients found Tangibility as least performance dimension (Lee & Yom, 2007). However, in a study conducted in a private hospital in Thailand to identify international patients’ satisfaction towards nurses service quality found that the patients overall level of satisfaction in the Tangible dimension was high (Chunlaka, 2010).

The statement “nurses should be polite” included in the Assurance dimension, had the highest patient expectation mean score. In congruent, the findings from patients’ perception of nursing service quality performance has shown that “nurses served me with politeness” had the highest mean score. This indicated patients expected as well as perceived nurses being compassionate, given service with respect which portrayed well-mannered behavior. In a study which evaluated patients satisfaction of nursing care has shown that when the patients were asked to provide suggestions to improve nursing care, 37.5% suggested nurses to care for them more by understanding their psychological needs, and 28.4% of them have suggested that the nurses should be more tolerant and respectful (Ozlu & Uzun, 2015).

The statement with lowest patient expectation mean score was “I expect nurses to tell me exactly when nursing services will be performed” from Responsiveness dimension. Similarly, the same statement in the patients’ perception of performance received the lowest mean score “nurses told me exactly when nursing services will be performed”. This result is interesting and could be due to majority of the nurses working in the hospital are non-native which diminishes the ability to maintain good communication with patients. According to Chunlaka (2010), providing prompt service with ability to communicate effectively can result in greater patient satisfaction and will inspire patients to return to the hospital if needs arise.

The difference between nursing service quality perception of performance score and nursing service quality expectation score by patients resulted negative gap score of -2.01, which indicated patients had higher expectation than the actual nursing service provided. The perceived service quality gap means that perceived or experienced service is not consistent with the expected service (Parasuraman et al., 1988). The gap score for the five dimensions of service quality indicated that patients’ expectations generally were not met except for Responsiveness dimension, which showed a positive gap score of 0.79. This demonstrated patient’s expectation was met as patients’ perception of nurses’ performance for this dimension was higher than patients’ expectation. This finding of positive gap for Responsiveness dimension also indicated patients had perceived nurses being attentive to the needs of patients in a timely manner. Responsiveness dimension had the smallest gap score statement “nurses were always willing to help me”. This could be result of nurses performing their duties according to standard of the hospital to evaluate and monitor patients’ clinical conditions whenever required and every four hours to ensure there are no complications.

In this study the greatest negative gap score was observed in Assurance dimension followed by Tangibility, Reliability and Empathy. SERVQUAL is a methodology that gives opportunity for health services to recognize potential areas for improvements in the service quality (Papanikolaou & Zygiaris, 2012). The statement “nurses get adequate support from the hospital to perform their services well” in the Assurance dimension had the highest gap score because of high expectation from patients. Negative gap score for Assurance may reflect the need for maintaining acceptable level of patient-to-nurse ratio, improving safety measures when performing nursing activities, maintaining up to date knowledge and competency plus the ability to inspire trust and confidence. In order to improve service quality for Tangibility, requires enhancing facilities of nursing care units as well as nursing staff to be well-dressed and neat in appearance. Negative service quality gap score for Reliability may reflect the need to hire and retain skilled nurses, evaluate or reward performances and provide training according to the required competencies. In order to achieve perceived nursing service quality for Empathy, nurses need to learn ways to demonstrate non-verbal expressions as well as verbal communications and how to give personal attention to patients depending on the situations. A study conducted among medical and surgical patients in a public hospital in Saudi Arabia has shown that all five service quality dimensions had negative gap scores (Al-Momani, 2016) and a study which compared patients expectation and perception about primary health care service quality showed negative service quality gaps in all dimensions  (Papanikolaou & Zygiaris, 2012). Hence, to provide quality nursing service, improvements are required to reduce the gap between patients’ expectation and perception of actual performance of service.

 

CONCLUSION

The findings of this study showed there was a gap between overall patients’ expectation and overall perception of performance of nursing service quality. The expectations were higher than performance in four dimensions of service quality. However, in the Responsiveness dimension patients’ perception of actual performance exceeded the expectation. In order to provide high quality nursing service the difference between expectation and performance need to be reduced. This study provides nurses information about aspects of nursing service that could enhance patients’ perception of quality nursing service, such as  responding to patients requests promptly, informing patients when nursing service will be performed, understanding needs of patients and showing willingness to help patients. Thus, it is essential for administrators to facilitate nursing service delivery process in such a way to meet patients’ expectations. It is vital for nursing staff to understand patients’ expectations towards their care and provide a service that meet these standards. Providing service consistent with patients’ expectations can result in patients to perceive positively about nursing service quality.

Further research is needed to explore more about vital aspects of nursing service quality and understanding out-patient satisfaction with quality of nursing service will be a benefit for improving the level of patient satisfaction.

 

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