Satisfaction with the quality of nursing care among older adults during acute hospitalization in Ghana

Abstract Aim This study assessed the level of satisfaction with the quality of nursing care among hospitalized older adults and the factors associated with it. Design This was a quantitative descriptive cross‐sectional survey. Methods We used a validated questionnaire to collect data from a convenience sample of 206 older adults from three government hospitals in Tamale, Ghana. Data were analysed using descriptive statistics, independent sample t test and one‐way ANOVA. Results Most of the participants (72.3%) reported moderate levels of satisfaction with the quality of nursing care, while 23.8% reported high levels of satisfaction. The association between gender, religion and level of satisfaction with nursing care was not statistically significant. However, patients differed on levels of satisfaction based on healthcare facility: patients at the Tamale Central Hospital were more satisfied with the quality of nursing care than those at the Tamale Teaching Hospital. There is a need for capacity building and sensitization workshops on the rudiments of geriatric care for nurses in the metropolis to serve as an impetus for improvement in the quality of care.


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FUSEINI Et al. Evidence shows that the extended family support system in Ghana has dwindled over the years due to rural-urban migration of the youth in search for employment opportunities in the big cities (Kpessa-Whyte, 2018;Tawiah, 2011). Ghana as a low-middle-income country has a huge healthcare infrastructural deficit. In 2018, Ghana had a total hospital bed capacity of 23,829 beds for a population of nearly 30 million people (United Nations Department of Economic and Social Affairs Population Division, 2019). This implies that older adults in Ghana who need medical attention must compete with the general population for the already overburdened healthcare infrastructure. This situation could have implications on the quality of care that older adults receive in Ghanaian hospitals. An assessment of hospitalized older adults' levels of satisfaction with the quality of nursing care will serve as an evaluation of the ability of the healthcare system in Ghana to provide safe and quality care that meets the multifaceted healthcare needs of older adults in the country.
Findings of the study will also serve as an impetus for capacity building and sensitization workshops aimed to improve geriatric care.

| BACKG ROU N D
Access to safe and quality nursing care is a basic human right and is important for the well-being of hospitalized older adults. The "Code of Professional Conduct" for nurses in Ghana requires nurses to render quality nursing care and to maintain the dignity of all patients regardless of age, gender, race or economic status (Nursing & Midwifery Council of Ghana, 2017). Available evidence suggests that hospitalized older adults are susceptible to physical and emotional abuse (Filipska et al., 2020;Naderi et al., 2019) as a result of the decline in physical and cognitive function associated with ageing (Animasahun & Chapman, 2017;Yatsuya et al., 2017). Hospitalization also poses a threat to the physical and psychosocial well-being of older adults Stewart & Arora, 2018). According to Hillman et al. (2013), older adults experience a myriad of negative emotions such as feeling of loneliness and isolation during hospitalization.
Efforts have been made by researchers to explore older adults experiences with care during acute hospitalization (Asmaningrum et al., 2020;Bridges et al., 2020;Kerr et al., 2020;Tadd et al., 2011).
These studies have identified incidents of negative experiences that ranged from negative attitude of healthcare professionals (HCPs) (Asmaningrum et al., 2020;Calnan et al., 2013;Tadd et al., 2011) to feeling of worthlessness and powerlessness without control of care decisions (Bridges et al., 2020;Tauber-Gilmore et al., 2018).
The majority of these studies, however, have been conducted using qualitative designs with high levels of subjectivity and limitations for generalizability.
Ghana has a low literate population of older adults as the majority of its older adult population are without formal education (Alhassan & Neysmith, 2013). Older adults in Ghana often face numerous challenges when accessing healthcare services including communication difficulties with HCPs, negative attitudes of HCPs, poorly designed healthcare infrastructure and difficulties in meeting healthcare cost due to inadequate health insurance coverage (Agyemang-Duah et al., 2019). Further, there have been media reports of older adults being refused access to healthcare services in Ghana because of lack of hospital beds for admissions (Akosa, 2018;Asamoah, 2018). The effects of these experiences on older adults' levels of satisfaction with the quality of nursing care have not been quantitatively explored.
Efforts have also been made by researchers to quantitatively estimate inpatients' satisfaction with nursing care to serve as an impetus for improvement in care Alasad et al., 2015;Al-Awamreh & Suliman, 2019;Chumbler et al., 2016;Haile Eyasu et al., 2016;Karaca & Durna, 2019;Özlü & Uzun, 2015;Razia et al., 2019). These studies have revealed differences in patients' satisfaction with nursing care across different geographic locations. For instance, while more than half (52.5%) of inpatients in Previous studies on patients' satisfaction with nursing care in the African context (Grace, 2018;Haile Eyasu et al., 2016;Mobolaji-Olajide et al., 2020;Yimer et al., 2021) lacked specificity for older adults as they involved all adult patients in their samples (young, middle-aged and older adults). No study has been identified that assessed hospitalized older adults' satisfaction with nursing care from the African perspective. Findings of studies on hospitalized older adults' satisfaction with nursing care from other continents may not be a representation of the perspectives of hospitalized older adults in Africa due to differences in sociodemographic characteristics.
This study, therefore, sought to assess the level of satisfaction with quality nursing care among older adults receiving acute healthcare services in public hospitals in the Tamale metropolis, Ghana. Nursing care is an inseparable component of health care and assessing hospitalized older adults' level of satisfaction with the quality of nursing care constitutes an integral part of the evaluation of the healthcare system. The findings of the study will create awareness of the current quality of nursing care in the Tamale metropolis.

| Research design
We employed a quantitative descriptive cross-sectional survey design in the present study. With the quantitative descriptive crosssectional design, measurements of both the independent and dependent variables are made on a single occasion.

| Research setting
The study was conducted in the Tamale Metropolis which is the capital town of the Northern Region of Ghana. Tamale is Ghana's third-largest city with a population of 360,579 people, according to the world population review (World Population Review, 2019). The town is located 600 km north of Accra, the capital city of Ghana.
Study participants were recruited from the three government hospitals in the Tamale metropolis: The Tamale Teaching Hospital (TTH), the Tamale Central Hospital (TCH) and the Tamale West Hospital (TWH).

| Population and sampling
The population for this study comprised all patients aged 60 years or more who had been on admission at any of the participating hospitals for at least three days. The total population was 421 patients. The participants were selected using a combination of quota sampling and convenience sampling methods. Quota sampling method was used to determine proportion of participants to include from each hospital; then, the participants from each hospital were selected using convenience sampling. The patients were selected based on the inclusion criteria of being 60 years or older, being admitted to the hospital for a period of three days or more, and ability to communicate effectively in the English language or Dagbani (a local dialect).
Patients who were unstable and those who were not in a position to give accurate responses were excluded from the study.

| Sample size
The sample size was determined using Yamane's formular (Yamane, 1967). This formular is used to estimate the sample size using the total population and the margin of error for a given study.
The formular is expressed as follows: Where n is the sample size, N is the population size, and e is the margin of error. Given a total population of 421 patients with 0.05 margin of error, the sample size was calculated as follows: Therefore, the sample size was 206 patients.

| Data collection tools
We gathered data for the study using a structured questionnaire.
The questionnaire comprised a demographic information section and the Patient Satisfaction with Nursing Care Quality Questionnaire (PSNCQQ), developed by Laschinger et al. (2005) The PSNCQQ is a 19 item scale with three additional questions designed to tap satisfaction with the overall quality of care during the hospital admission, overall quality of nursing care and intention to recommend the hospital to family and friends. Each item is measured on a 5-point Likert scale from strongly agree to strongly disagree. The PSNQQ was a suitable scale for the study as it was designed to solicit feedback on the quality of nursing care from patients' perspectives. The questionnaire has an excellent internal consistency with a Cronbach's alpha value of 0.97 (Laschinger et al., 2005).
A multi-step forward-backward translation of the questionnaire from the English language to Dagbani and back to the English language was undertaken by two professionals who are prolific speakers of both languages. The two professionals independently translated the original questionnaire from the English language to Dagbani. Following the initial translation, they met to discuss the translation process and produced a single copy of the translated questionnaire by consensus. A third professional who is a native speaker of Dagbani and also proficient with the English language was contacted to translate the Dagbani version of the questionnaire back to the English language.
Content validity of the questionnaire was assessed with five experienced nurses using the Content Validity Index (CVI) (Polit & Beck, 2006). The nurses were tasked to rate each item on the ques-

| Data collection procedure
Following ethics and institutional approval, we visited the wards of the participating hospitals and identified patients who met the inclusion criteria. We sought permission from the ward nurses and approached the identified patients to explain the study to them, what participation involved and participant rights. We encouraged them to ask questions about the study and assured them that participation was totally voluntary. Those who agreed to participate in the study were recruited after signing an informed consent. We personally administered the questionnaires to all participants. For patients who were not literate, we read out the questionnaire to them in the local dialect and recorded their responses. Participants were allowed to complete the questionnaire at their own convenience. Data collection took place over a pe-

| Data analysis
We analysed the data using the Statistical Package for Social Sciences (SPSS) version 22 (IBM, 2015). We used descriptive statistics to summarize demographic and other background characteristics of participants and to present their levels of satisfaction with quality of nursing care. We determined patients' levels of satisfaction with the quality of nursing care by calculating the average total scores of all items on the PSNCQQ. This calculation resulted in a range of scores from 22-110. We put the patients into three levels of satisfaction based on their total scores on the PSNCQQ. The levels were low satisfaction (22-50), moderate satisfaction (51-80) and high satisfaction (81-110). We also used the independent sample t test to assess differences in the level of satisfaction with quality of nursing care between males and females.
Lastly, we conducted a one-way ANOVA to determine differences in the level of satisfaction with quality of nursing care based on religion, level of education and the admitting hospitals.

| Ethical considerations
We obtained ethical clearance for the study. We also sought permission from the management of the participating hospitals before the data collection process began. Besides, we explained the purpose and potential benefits and risks for participating in the study to the participants in the English language or Dagbani (local dialect) before the data collection. The participants were given a 24 hr period to consider their participation from the time they were approached to take part in the study. Participants who agreed to take part in the study were made to give their consent by signing the consent form. We also informed the participants that they could withdraw from the study at any time even after giving their consent and that refusal to participate in the study will not affect the quality of service they received from the hospitals.

| Demographic/background characteristics of participants
Out of the total number of participants whom the questionnaires were administered to, 206 participants eventually completed the survey. The majority of the participants 128 (62.1%) were males, without formal education (54.9%), married 145 (70.4%) and belonging to the Islamic faith 160 (77.7%). Other characteristics of the participants are presented in Table 1.

| Satisfaction with quality nursing care
A large majority of the participants 149 (72.3%) reported moderate levels of satisfaction with the quality of nursing care received at the various hospitals. With satisfaction scores ranging from 22-110, the mean score was 74.126, with a standard deviation of 9.999. Participants' levels of satisfaction with the quality of nursing care are presented in Table 2. We also compared the level of participant satisfaction with the quality of nursing care across the three different hospitals. The findings are presented in Table 3.

| Association between satisfaction with nursing care and selected background characteristics of participants
To determine factors influencing satisfaction with nursing care, we compared the level of satisfaction of participants using different  test revealed that the mean satisfaction score for participants admitted to the Tamale Central Hospital was statistically significantly higher (76.078 ± 8.095, p = .001) than those admitted to Tamale Teaching Hospital (70.235 ± 9.272, p = .001). The satisfaction scores for participants admitted to the Tamale West Hospital were not statistically different from the other facilities (p = .586). Further details of the one-way ANOVA are presented in Table 4.

| DISCUSS ION
The findings of our study indicated that a greater percentage of the participants were moderately satisfied with the quality of nursing care at the various government hospitals in the Tamale metropolis.
Only a smaller percentage of the participants reported high levels of satisfaction with the quality of nursing care. In tandem with our findings, previous studies have reported that the majority of hospitalized older adults are either dissatisfied or moderately satisfied with the quality of care rendered at hospitals Shady et al., 2018). Nearly three quarters of the participants were unsatisfied with the quality of nursing care in Shady et al.'s (2018) study, while the same proportion of participants reported moderate levels of satisfaction with care in a study by Ahmadabad et al. (2016).
Only a small fraction of our participants reported high levels of satisfaction with the nursing care, and this came as no surprise to the research team. Ghana does not have a geriatric nursing programme or an aged care support system for its older adult population. As a consequence, older adults in Ghana compete with the general population for healthcare services that is already overstretched due to inadequate infrastructure. As part of measures to improve care for older adults, hospital managements and other relevant stakeholders should organize capacity building and sensitization workshops on the rudiments of gerontological nursing in the interim. In the long run, the government must improve on the healthcare infrastructure in Ghana and introduce specialist geriatric nursing programmes that will equip nurses with the requisite skills to meet the multifaceted needs of hospitalized older adults.
Regarding factors influencing satisfaction with the quality of nursing care, we found that gender, religion and educational attainment did not appear to influence participants' level of satisfaction with nursing care. In conformity with our findings, several  (Kazerooni et al., 2019;Özlü & Uzun, 2015). Other studies, on the contrary, have observed a statistically significant difference in the levels of satisfaction with nursing care between male and female older adults, with females more likely to be satisfied with the quality of nursing care than their male counterparts (Chumbler et al., 2016;Haile Eyasu et al., 2016)

| CON CLUS ION AND RECOMMENDATIONS
Our findings revealed that the majority of older adults in the Tamale Metropolis are moderately satisfied with the quality of nursing care they receive at the various public hospitals in the metropolis with just a small proportion reporting high levels of satisfaction with nursing care. We also observed that hospitalized older adults at the Tamale Central Hospital are more satisfied with the quality of nursing care that those admitted at the Tamale Teaching Hospital. We conclude that besides the differences in the admitting facilities, other demographic characteristics such as gender and religion do not influence hospitalized older adults' levels of satisfaction with quality nursing care. There is a need for capacity building and sensitization workshops on the rudiments of geriatric care for nurses in the metropolis to enable them to improve on the quality of nursing care services for hospitalized older adults. The government of Ghana must introduce a specialist programme in geriatric nursing to equip nurses with the requisite knowledge and skill that will meet the multifaceted needs of hospitalized older adults.

ACK N OWLED G EM ENT
We extend gratitude to older patients and their families at the various recruiting hospitals for their participation in this research project.

CO N FLI C T S O F I NTE R E S T
The authors declare no conflict of interest.

AUTH O R CO NTR I B UTI O N S
The first author conceptualized the research topic and drafted the proposal for the project. He also wrote the discussion, conclusion and recommendations of the paper with support from the other authors. The second and fourth authors were responsible for the collection of the data for the project, while the third author assisted in the analysis of the data and writing of the report of the findings.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data sets generated and analysed during the current study are available from the corresponding author on request.