Patient satisfaction with nursing care in an Intensive Care Unit measured through the Nursing Intensive-Care Satisfaction Scale (NICSS)

Abstract

Background

Patient satisfaction in relation with nursing care has become a key determinant of the quality of hospital care.

Objectives

To evaluate patient satisfaction in relation with nursing care in a critical care context; to determine the correlation between critical patient satisfaction and sociodemographic and clinical variables and to describe patient perceptions with nursing care.

Methods

A descriptive, prospective, correlational study which includes the analysis of some open questions in the intensive care unit (ICU) of a tertiary level university hospital. The degree of satisfaction of all patients discharged from de ICU was evaluated. It was used the validated Spanish version of Nursing Intensive-Care Satisfaction-Scale (NICSS). There were also collected sociodemographic and clinical data and 3 open questions were asked. It was used the inferential and descriptive statistics considering statistically significant p < .05. Open questions were examined using a language context analysis. The approval of the hospital ethical committee was obtained.

Results

111 patients agreed to participate, with a mean age of 64.18 years (CI 95% 61.36–66.88) and with a medium level of satisfaction of 5.83 (CI 95% 5.78−5.88) being 6 the maximum score. Women, older patients and those who reflect a higher degree of recovery, are those who reported greater satisfaction. Three main themes emerged from the analysis of the open-ended questions of the surveys: nurse patient relationship, professional practice environment and ICU nature.

Conclusion

Patient satisfaction in relation with nursing care was elevated. Age, sex and degree of recovery significantly influenced their perception. Nurse patient relationship and the professional practice environment were aspects highlighted by patients. The professional model incorporated by the institution may encouraged these results.

Resumen

Introducción

La satisfacción del paciente con los cuidados enfermeros se ha convertido en un determinante clave de la calidad de la atención hospitalaria.

Objetivos

Evaluar la satisfacción con los cuidados enfermeros en el contexto del paciente crítico; determinar su correlación con las variables sociodemográficas y clínicas y describir las percepciones del paciente sobre aspectos relacionados con el cuidado enfermero.

Metodología

Estudio descriptivo, prospectivo, correlacional en la Unidad de Cuidados Intensivos (UCI) de un hospital universitario de nivel terciario. Se evaluó el nivel de satisfacción a todos los pacientes dados de alta de la UCI. Se utilizó la escala validada en castellano Nursing Intensive-Care Satisfaction-Scale (NICSS). Además, se recogieron datos sociodemográficos y clínicos, y se realizaron 3 preguntas abiertas. Se utilizó estadística descriptiva e inferencial considerándose estadísticamente significativos p < 0,05. Las preguntas abiertas se examinaron mediante un análisis de contenido del lenguaje. Se obtuvo la aprobación del comité de ética del hospital.

Resultados

111 pacientes aceptaron participar, con una media de edad de 64,18 años (IC 95% 61,36–66,88). y un nivel de satisfacción medio de 5,83 (IC 95% 5,78−5,88) de una puntuación máxima de 6. Las mujeres, los pacientes de mayor edad y los que reflejan mayor grado de recuperación, son los que refieren mayor satisfacción. Del análisis de las preguntas abiertas de las encuestas surgieron tres temas principales: relación enfermera paciente, entorno de la práctica profesional y naturaleza de la UCI.

Conclusión

El nivel de satisfacción de los pacientes con los cuidados enfermeros fue elevado. La edad, el sexo y el grado de recuperación influyeron de manera significativa en su percepción. La relación enfermera paciente y el entorno de la práctica profesional fueron aspectos destacados por los pacientes. El modelo de la práctica profesional incorporado en la institución puede favorecer estos resultados.

What is known?

The structure of intensive care units, together with the severity of the patients and the extensive use of technology, can violate the dignity and autonomy of admitted patients. There is a risk of putting technical care before human care and not considering the person holistically. To avoid falling into this tendency, particular interest should be paid to the patient's perceptions. Numerous studies support that patient satisfaction is the best indicator of quality of care.

What is the contribution of this?

By evaluating the level of satisfaction with nursing care and the aspects of care that patients identify, we are able to determine what the key points of their care are. Furthermore, it suggests that the model of professional nursing practice that guides the practice of professionals favours patient satisfaction.

Implications of the study

Knowing the patient's satisfaction with care enables us to design interventions to personalise patient care, taking into account their needs and expectations.

Introduction

Intensive Care Units (ICU) are complex, highly specialised units, in which patients in critical conditions are admitted, requiring highly competent health professionals.¹ This requires nurses to have specialised training that provides them with scientific-technical knowledge, guaranteeing adequate safety, quality and efficiency conditions to care for critically ill patients. In so doing, they will be trained to holistically assess the patient and develop a personalised care plan.^1,2

However, the structure of these units, together with the severity of the patients and the extensive use of technology, can violate the dignity and autonomy of the person. There is a risk of putting technical care before human care and not considering care holistically. Prioritising the biological aspect, leaving aside the social, psychic and spiritual dimensions, causes the patient to be treated as an object rather than a person.^3,4

To avoid falling into this tendency, particular interest should be paid to determining the patient's perceptions. In recent decades there has been a paradigm shift, in which patients participate dynamically in healthcare activity, so that their satisfaction is the central aspect of said care.^5,6 In fact, numerous studies support that patient satisfaction is the best indicator of quality of care.^7–9

According to the WHO, quality in health care is to ensure that each patient receives the most appropriate set of diagnostic and therapeutic services to achieve optimal health care, taking into account all the factors and knowledge of the patient and the medical service, and achieving the best result with the minimum risk of iatrogenic effects and maximum patient satisfaction with the process.¹⁰

Measuring satisfaction with nursing care from the patient's perspective is therefore a key element in the evaluation of healthcare quality.^4,7–9,11 By doing this it becomes possible to identify points for improvement and establish measures to ensure the quality of care.⁷ To guarantee this quality, nurses must acquire skills that ensure technical care and human attention, highlighting interpersonal skills that enhance the relationship with the patient and family.^3,4 All these actions must be oriented towards continuous improvement and the execution of strategies that cover all dimensions of the person.^3,4

This study was therefore carried out with the objective of evaluating satisfaction with nursing care in the context of critically ill patients, determining the correlation between critical patient satisfaction and socio-demographic and clinical variables, including a description of the patient's perceptions about aspects related to nursing care.

Methodology

Descriptive, prospective, correlational study carried out in a multipurpose ICU, belonging to a tertiary university hospital with more than 200 beds. This hospital cares for patients from medical insurance schemes, private health services and, to a lesser extent, the National Health System. This ICU has 12 beds and treats around 800 patients annually, 80% of which are surgical. The remaining 20% correspond to medical patients, with multiple pathologies and/or in need of advanced therapies. The nurse-to-patient ratio for this unit is 1:2.

Subjects

All patients who met the following inclusion criteria were invited to participate: aged over 18 years; conscious and aware and oriented in time, place and person during admission; being able to express themselves in Spanish and having given verbal and written informed consent. Patients who were discharged to another hospital or who were discharged directly to their home were not included.

The sample selection was of convenience.

Data collection tools

To collect data, the research team prepared a document that included:

• -

  Socio-demographic data of the patients: age, sex, financing of health care, marital status, employment status, dependents, level of education, days of admission to the ICU, previous admission to the ICU, reason for admission, perception of their current health and degree of recovery after their stay in the ICU.

• -

  The Nursing Intensive-Care Satisfaction-Scale (NICSS) questionnaire.⁵ This scale was developed and validated in Spanish, and has 49 items that evaluate 4 factors of the quality of care. The first three factors of the NICSS refer to the patient’s experiences in relation to the nursing care received with a total of 37 items, 20 corresponding to Factor 1: Holistic Care (physical and emotional aspects), 6 items to Factor 2: Forms of Communication (verbal and non-verbal) and 11 items to Factor 3: Professional Behaviour. Factor 4: Consequences refers to the feelings they experienced as a result of the nursing care received with a total of 12 items.

• -

  Each of the items is measured according to a Likert-type scale with 6 response options (from 1 strongly disagree to 6 strongly agree). In Factor 4, there are three items (44, 48 and 49) formulated positively but expressing an unfavourable opinion; therefore, the score is reversed. In this way, the overall score and that of each factor is the average of the sum of the item scores. The person is considered dissatisfied when the average score is between 1 and 3.5 and satisfied when the average score is >3.5.

• -

  The reliability of the scale measured with Cronbach’s α is .97 and the 4 factors have values between .87 and .96. The intraclass correlation coefficient for the total scale was .83, indicating good temporal stability. Criterion validity presented a moderate to high correlation (range: .46–.57).¹²

• -

  The research team chose this scale because it is specific to the ICU and includes the perspectives and needs of patients specific to these units.⁶ The authors gave their permission for its use.

• -

  A questionnaire with 3 questions with Likert-type response options to support the scores obtained from the scale, and 3 open questions to describe aspects of care that patients identified.³ These questions were: 1) What nursing care received has helped you the most during your stay in the ICU? 2) What nursing care received has helped you the least during your stay in the ICU? and 3) Comments or specific situations that you wish to express.

All questionnaires were self-administered.

Data collection was carried out by the research team during the period between December 2022 and February 2023. Patients who met the inclusion criteria of the research, once discharged from the ICU and on the ward, were informed of the study and asked for their voluntary participation. If they agreed to participate, a person from the research team who had not had prior contact with the patient explained the questionnaire to them and, if required, they were helped to complete it. At that time, the collection date was agreed with the patient.

Descriptive and inferential statistics were used to analyse the quantitative data. The values were expressed as mean and their 95% confidence interval (95% CI), and the categorical variables as numbers and percentages. To analyse the differences between two groups, the Student's t-test was performed for unpaired samples, as long as normality was demonstrated (Shapiro-Wilks test). Otherwise, a non-parametric test was used (Mann U test). Whitney). To analyse the differences between more than 2 groups, the Anova test was used in the case of parametric variables and the Kruskal-Wallis test in the case of non-parametric variables. Categorical variables were studied using the chi-square test or Fisher's exact test. Correlations between continuously distributed variables were evaluated using Sperman's correlation coefficient. P < .05 was considered a statistically significant difference. The statistical analysis was carried out using the IBM SPSS version 20 programme (SPSS Inc., 2003).

The open questions of the patient surveys were examined through a language content analysis, using one of the three coding methods proposed by Hsieh and Shannon¹³ called “conventional”, characterised by coding not carried out with pre-established codes, but with those that emerge from the data. Content analysis was performed manually. The essential steps carried out were:

• 1

  Reading each of the questionnaires to obtain the overall meaning of the text.

• 2

  When the overall meaning was obtained, going back to the beginning and reading the text again, with the aim of discriminating between the “meaning units” (segments of the collected data that potentially reveal some aspect of the phenomenon that is being investigated).

• 3

  Once these units had been identified and coded, they were grouped by common meanings and transformed into the language of the discipline, giving rise to “statements of meaning “to be included within each topic.

To analyse the data objectively and minimise possible biases, an exhaustive analysis process was carried out among the different members of the research team. The process carried out was: 1. Each researcher individually analysed the open questions of all participants, highlighting the units of meaning. They then grouped the meaning units into meaning statements and the statements into themes. 2. In pairs the researchers contrasted the analysis they had performed to combine criteria and reach a common result.

Ethical considerations

Approval was obtained from the hospital's ethics committee and the centre's management for its implementation. All participants were guaranteed anonymity, complete confidentiality of the data, as well as the destruction of the questionnaires at the end of the research (Organic Law 3/2018, of December 5, on the Protection of Personal Data and guarantee of digital rights). Written consent was obtained from the participants.

Results

Of the 111 patients who participated in the study, 64.90% (n = 72) were men and 35.10% (n = 39) were women. The mean age was 64.13 (95% CI 61.36−66.88). The sociodemographic and clinical data of the sample are collected in Table 1.

Table 1.

Socio-demographic characteristics of the sample.

	% (n)
Age
x̄ (95% CI)	64.13 (61.36−66.88)
Sex
- Man	64.90 (72%)
- Woman	35.10 (39%)
Level of education
- University level	43.90 (46)
- Non-university level	56.10 (59)
Employment status
- Active	41.20 (47)
- Retired	58.80 (64)
Civil status
- Married/living with partner	76.20 (83)
- Other situations	23.80 (28)
Dependents
- Yes	20.00 (20)
- No	80.00 (80)
Healthcare funding
- Medical insurance scheme	37.80 (42)
- Private	36.00 (40)
- National health service	26.10 (29)
Reason for admission
- Medical	24.80 (27)
- Surgical	75.20 (82)
Previous admission to ICU
- Yes	43.10 (47)
- No	56.90 (62)
Length of stay (days)
x̄ (95% CI)	3.05 (1.98−4.14)
Current perception of health status
x̄ (95% CI)	6.58 (6.21−6.95)
Recovery level
x̄ (95% CI)	6.93 (6.56−7.30)

The mean NICSS scale score was 5.83 (95% CI 5.78–5.88) out of 6 (min: 5.45 max: 5.94). Table 2 presents the results of the levels of satisfaction obtained in each factor, the items that patients reflected as dissatisfied and the NICSS items that scored the best (score ≥ 5.92) and the worst (score < 5.63).

Table 2.

Mean score for factors and items of the NICSS scale.

	Dissatisfied n %	Satisfied n %	x̄(95% CI)
Factor 1: Holistic care			5.87 (5.83−5.93)
Item 6: They ensured I was not in pain	0 (0)	111 (100)	5.93 (5.87−5.98)
Item 7: They gave me my medication on time	0 (0)	111 (100)	5.92 (5.86−5.98)
Item 8: They listened to me when I needed it	1 (.90)	110 (99.10)	5.88 (5.80−5.96)
Item 16: They respected my sleep and rest	3 (2.70)	108 (97.30)	5.66 (5.52−5.78)
Item 17: They treated my injuries well	0 (0)	111 (100)	5.93 (5.88−5.97)
Item 19: They were concerned for my comfort	0 (0)	111 (100)	5.96 (5.90−5.99)
Item 22: They were attentive to my needs	0 (0)	111 (100)	5.93 (5.88−5.98)
Item 23. They showed patience during my care	0 (0)	111 (100)	5.92 (5.86−5.98)
Factor 2: Communication modes			5.87 (5.82−5.92)
Factor 3: Professionals behaviours			5.86 (5.81−5.91)
Factor 4: Consequences			5.70 (5.62−5.78)
Item 40: They valued my opinion with regards to care	2 (1.80)	109 (98.20)	5.63 (5.49−5.77)
Item 42: I was in “the nurse’s hands” due to my dependent status	7 (6.30)	104 (93.70)	5.57 (5.38−5.76)
Item 44: Like a number, an objects	11 (9.90)	100 (90.10)	5.45 (5.17−5.73)
Item 48: Alone	11 (9.90)	100 (90.10)	5.49 (5.22−5.76)
Item 49: Unattended	8 (7.20)	103 (92.80)	5.58 (5.34−5.83)

Regarding the questions in the third questionnaire, the average score was high. To the question of “I feel satisfied with the care given by the nurses”, and “If I needed help again, I would like to be cared for in this ICU again”, 100% of the patients were satisfied with an average score of 5.90 (95% CI 5.85–5.96) and 5.93 (95% CI 5.87−5.98) respectively. Regarding “The care given by the nurses is as I expected” 98.20% of the patients were satisfied, with a mean of 5.77 (95% CI 5.66–5.88).

Table 3 shows the relationship between the mean score of the scale and its factors with socio-demographic and clinical data.

Table 3.

Relationship between the men score of the scale and its factors, such as socio-demographic and clinical data.

	Overall score	Holistic mean	Communication	Consequences	Behaviours
Age	r = .243 p = .010	r = .160 p = .095	r = .235 p = .014	r = .256 p = .007	r = .209 p = .028
Sex	p = .009	p = .499	p = .541	p = .002	p = .523
Civil status	p = .424	p= .686	p = .434	p = .624	p = .195
Healthcare funding	p = .782	p = .964	p = .651	p = .592	p = .770
Employment situation	p = .093	p = .497	p = .316	p = .04	p = .708
Dependents	p = .279	p = .569	p = .499	p = .186	p = .140
Education	p = .230	p = .092	p = .738	p = .906	p = .475
Length of stay in days	r = −.096 p = .319	r = −.065 p = .498	r = −.072 p = .455	r = −.093 p = .332	r = −.023 p = .813
Reason for admission	p = .090	p = .175	p = .099	p = .093	p = .202
Previous admission	p = .182	p = .443	p = .811	p = .218	p = .811
Current perception	r = .125 p = .207	r = .312 p = .001	r = .232 p = .018	r = .013 p = .900	r = .250 p = .011
Recovery level	r = .219 p = .026	r = .355 p < .001	r = .327 p = .001	r = .111 p = .266	r = .311 p = .001

The variables that present a statistically significant relationship with the level of satisfaction of the NICSS global score were sex (p = .009), age (r = .243 p = .010) and degree of recovery (r = .219, p = .026). Women, older patients and those who reflect a greater degree of recovery are those who report greater satisfaction. Likewise, for some of its factors.

The current perception of health status significantly influences the holistic factor (r = .312, p = .001), the communication factor (r = .232, p = .018) and the behaviour factor (r = .250, p = .011). Patients with a better perception of their health status rate satisfaction with care more positively.

Of the 111 patients evaluated, 103 made comments on some of the survey questions. The question that patients referred to most, specifically 98 patients, was “What nursing care received has helped you the most during your stay in the ICU?” The second question, What nursing care received has helped you the least during your stay in the ICU?, obtained 67 responses and of those 67, 52 stressed that there had been nothing that had not helped them: “Nothing, everything I received has been of great help to me” (P.48); “I haven't missed anything” (P.2). The last question “Comments or specific situations that you wish to express” collected 70 comments.

Three main themes emerged from the analysis of the open questions: 1) The nurse-patient relationship, 2) The professional practice environment, and 3) The nature of the ICU. Table 4 shows the main themes with their statements and units of meaning. Each of these themes is presented below, supported by textual expressions from the participants.

Table 4.

Significant themes and statements.

Theme	Significant stsatements	Significant units
The nurse-patient relationship	Awareness	Personalised carePatient’s opinionKnowledge of medical history
	Authenticity	AffectionKindnessPatienceTendernessSensitivityGenerosity
	Trust	TrustSecurityTranquillityCosy/family-like situation
	Concern	Being attentiveModes of comfortAttention to detailAttentive to callsEncouragingOptimismEmpathy
	Intentional presence	Being beside themCompanySupportCommunicationHelpClosenessConstant careDispositionDevotionDedication
	Respect	ComprehensionAffection/humane careFriendlinessCareBeing attentive to needs
The professional practice environment	Teamwork	PersonnelTeam
	Autonomy	ProfessionalismGood careInformationEfficiencyEfficacyRapidity of response
	Evidence-based practice	KnowledgePracticeKnowhow/willingness to act
	Responsibility	Trainee staff
The nature of the ICU	Physical structure	Architectonic aspectsTechnological aspectsEnvironmental aspectsAspects related to the family
	Process driven care	MasksMonitoringAnalytical testsBIPAPHygiene Covid PCRCareSeverity of the processes

The nurse-patient relationship

The interpersonal relationship with the nurse was mentioned by 86 patients. Included within this theme were elements about nurses' knowledge, authenticity, trust, concern, intentional presence, and respect.

Patients pointed out aspects related to the nurse's knowledge of them. Thus, to the question, what nursing care received has helped you the most during your stay in the ICU?” P.9 expressed: “when they took into account my opinion about my care and respected it without getting angry” and P.83 “their knowledge of my history and acting at all times accordingly (…).

Authenticity was reflected in the affection, sympathy, patience, tenderness, sensitivity and generosity that patients perceived from the nursing staff. P.56 showed it this way: “protocols, procedures can be applied… but they never change the loving look they give the patient. It's great!!, and P.102 commented: “sensitivity, kindness and a feeling of affection.” Another comment was: “The love and kindness of expert nurses” (P.21). There was one patient who related the treatment to the level of expertise of the professionals; “For a time there were recently graduated nurses, less experts (not all of them) which was reflected in the personal treatment” (P.9).

The trust that patients mentioned referred to the security, tranquillity and familiarity of the care received. To the questions, what nursing care received has helped you the most during your stay in the ICU?” and the request for any specific comments or situations that patients wish to express, their responses were: “trust they have given me” (P.5), “the ability to make you feel safe” (P.107), “Despite being “strangers”, they have made my stay a cosy and family-like situation” (P.53).

Regarding concern, patients expressed attributes such as empathy, encouragement, optimism that the nurse transmitted to them and the actions carried out to maintain their well-being. P.7 quoted verbatim “that they have treated me well and were attentive at all times to make me feel as good as possible.” P.99 stated, “If they find you sad, they talk to you, they encourage you” and P.98 “Their optimism, empathy, understanding and desire to please to make you feel good.”

None of the patients’ responses regarding these aspects contained negative comments.

In relation to intentional presence, patients reflected the closeness they perceived and the nurse's disposition. “Their attention, they sat with me on the bed to talk” mentioned P.40 and P.72 noted “the closeness that I have felt at all times.” However, three patients mentioned aspects that could be improved when they referred to the time the nurses stayed in the room and the explanations provided. “Sometimes they came in very quickly and I was left alone for a long time, waiting for care” (P.9) and “Somewhat brief explanations for companions in certain situations (

Understanding, affection, humane treatment, kindness, care and being aware of needs were aspects that expressed the respect patients received. This was the most commented upon statement. P.113, in the section on comments or specific situations that they would like to express, stated: “from the moment you enter the UCI you feel that you are in the best hands and with an incredibly family-like humane treatment.” To the question, What nursing care received has helped you the most during your stay in the ICU?” P.98 highlighted, “(…), understanding and desire to please to make you feel good” and P.47 “The treatment received and the kindness of all the staff. “Unbeatable.”

The professional practice environment

Forty patients mentioned the professional practice environment in their comments. With this, they made reference to teamwork, autonomy, practice guided by evidence and responsibility.

Regarding teamwork, patients reflected positive aspects of it. P.66 commented “nothing, everything has been perfect. I can't say anything else about the excellent UCI team” and P.119 “the great teamwork”.

The comments alluded to the autonomy of the nurses, highlighting their professionalism, care, information received, efficiency, effectiveness and speed of response. To the questions, what has helped you the most? and comments that they wish to express, the patients quoted verbatim “(…) always very effective in their work and care” (P.74) and “feeling that they were in the hands of efficient professionals in control (…)” (P. .94). Other comments were: “I was pleasantly surprised by the high quality of the ICU nursing” (P.2); “My great gratitude to the attention, professionalism (…) of the ICU professionals” (P.92) and “the speed of the response (…)” (P.97)”.

Evidence-guided practice was another characteristic mentioned. This is how several of them expressed it: “(…) act at all times in accordance with it and the best practices” (P.83) and “(…) wanting to do things well” (P.72).

None of these aspects received negative comments from patients.

In relation to responsibility, two comments made by patients referring to intern staff highlighted aspects that could be improved; “too many trainee staff without immediate supervision” (P.78) and “in the end I felt that my new nurse was not very sure of what she was tasked with. She was not an ICU nurse” (P.51).

The nature of the ICU

The physical structure and the care derived from the process are the two factors that encompassed the nature of the ICU. This topic was the least referenced by patients in their comments (20 patients).

Regarding the physical structure, patients described architectural, technological, environmental and family-related aspects: “we appreciate that they allow visitors and have a separate room in the ICU. (…)” (P.54) and “technology and especially the presence of family members” (P.100).

Noise focused patients' attention on the environmental aspect. All the comments spoke about this issue, highlighting it as an aspect for improvement, “in relation to question numbers 16 and 51, there was a time when it was impossible to be quiet, a lot of noise. Good at night. In the morning the commotion begins, astonishing. If they correct that, I wouldn't mind coming back” (P.77). P.41 stated “too much noise at night, conversations and machine beeps.”

Patients also pointed out aspects of care derived from the process of their illness. They referred to the need for monitoring, hygiene procedures or analytical extraction. This was stated by P.68 “having controlled the pneumonia and during the process having felt very good about the care received and their attention” or P.92 “the constant interruption of sleep, although I understand that it was necessary to carry out the monitoring tasks.” Other comments were: “the movements during washing” (P.15) or “the unhealthy obsession with masks and the pressure that my relatives suffered due to the COVID protocol” (P.100). “

Discussion

Level of satisfaction

This study shows that patients admitted to the intensive care unit have a high level of satisfaction with the nursing care received during their stay. The result coincides with that of other investigations in which other assessment instruments were used.^9,14–17 Furthermore, it is superior to the studies by Romero-García et al.¹⁸ and Delgado-Hito et al.⁸ that use the same scale.

This finding may be due to the fact that all nurses working in the unit received the same specialised training programme that included scientific-technical and human aspects.¹⁹ In addition, together with the supervisor they carry out an annual self-evaluation with the aim of establishing points for improvement. This evaluation involves ethical aspects, practice, teaching and research. Likewise, the hospital where the research was carried out is accredited by the Joint Commission International (JCI), an external audit that evaluates the quality and safety of healthcare organisations every 3 years. This makes maintaining high quality standards a priority for the institution and all its professionals.²⁰

The holistic factor that evaluates physical and emotional aspects was the best rated, with items 6 (they have tried to ensure that I do not have pain), 7 (they have administered the medication on time), 19 (they have made sure that I was comfortable) and 22 (they have been attentive to my needs) being the ones that obtained the highest level of satisfaction, as they did in the literature reviewed.^8,18 According to other research, receiving humane care, attending to needs and with patience are aspects highly valued by patients. Better, more technically competent care from the nurse also has a positive influence on the degree of satisfaction.^6,15

The worst valued factor, although also with a positive score, was the Consequences factor, which refers to the feelings that patients experienced as a consequence of the nursing care received. This result coincides with the research of Delgado et al.⁸ This finding is striking since, analysing the questionnaires, the patients who gave the lowest scores on this factor make positive comments on the open questions and rate the third questionnaire very positively. This suggests that the patient did not correctly interpret some of the questions, especially those that, being formulated positively, express negative ideas.

Socio-demographic, clinical and organisational factors

By relating the socio-demographic variables to the level of satisfaction, it becomes evidence that sex and age influence satisfaction, a controversial fact in the reviewed literature. Some authors find that women report a higher level of satisfaction with the care received,^21,22 as in this study. Other research, however, finds that men score significantly better,^9,23–25 and in other studies, there is no association.^8,18,26–29 Regarding age, older patients expressed more satisfaction as stated in the literatura.^{6,9,24,25,30,31} On the contrary, other investigations do not find an association.^8,32 This may be due to the use of different instruments to evaluate satisfaction. It is important to highlight that, although there are significant differences, in the present study there is no clinical relevance in the result because both scores are highly satisfactory.

Patients who reflect a greater degree of recovery are those who report greater satisfaction, as reported in the reviewed literatura,^8,33 in contrast to other studies,¹⁸ It is described in the literature that patients who perceive their recovery as early and successful show a higher degree of satisfaction.^8,27,28

The current perception of the state of health significantly influences the holistic factor, the communication factor and the behavioural factor. Patients with a better perception of their health status value these aspects more positively. The way the person perceives is conditioned by personal needs, previous experiences, the self-perceived role of the care provided and situational factors that, in one way or another, influence the way the patient will express the characteristics of the care provided.^10,16,17

Open-ended question analysis

Patient comments were divided into three main themes: the nurse-patient relationship, the professional practice environment, and the nature of the ICU. The first two reflect aspects of the model of professional nursing practice of the hospital where the study was carried out. This model places the nurse-patient relationship at the core of nursing practice. This relationship, considered bidirectional, is made up of the values, beliefs and expectations that both have.³⁴

Great relevance is attached to the nurse-patient relationship. Proof of this are the observations made by patients. Of the 86 patients who provided comments, only three suggested signs of improvement. The most valued attributes were: humane treatment, closeness, empathy, security, encouragement received and understanding, similarly to the literature reviewed.^4,28,30 This may be due to the emphasis that the study centre's professional practice model places on providing a relationship marked by authenticity, intentional presence, knowledge of the patient, trust, concern and respect.³⁴ Caring from a respectful, close and authentic relationship means sharing common goals. These objectives are achieved when the nurse knows the patient and through her presence addresses their needs and experiences.³⁴ Patients feel the nurses know them when they experience that they are treated as unique human beings. They feel safe, they experience a meaningful and personal connection with their nurses, and they feel empowered and encouraged to participate in their care.³⁵

Comments related to the professional practice environment highlighted patient satisfaction with autonomy, evidence-based practice, and teamwork, as did the literature reviewed.^4,11 In the study by Lu et al.,¹¹ patients positively mentioned aspects related to speed of response, know-how and professionalism. Likewise, in the research by Pedreschi et al.,⁴ on the perception of care, they found that, for both the patient and the nurse, technical-scientific knowledge and skills are important. All of these attributes are so important that they can either limit or enhance the care provided.³⁶ The result obtained in this research may be due to the fact that the professional practice model that defines the institution where the study was carried out uses a practice environment that highlights the participation of nurses in patient and family care, so that they are in a position to transform the institution. Likewise, through excellent practice and personal leadership, they are encouraged to work according to their abilities and competencies, thus obtaining the best clinical results.³⁴

Regarding the nature of the ICU, patients showed satisfaction with their family visits during their stay in the unit. This may be due to the long visiting hours (from 11 a.m. to 2 p.m. and from 5 p.m. to 9 p.m.) of the unit. Also, several family members are permitted entry, with greater flexibility, in keeping with the needs of the patient and their family, and the possibility of making phone calls at any time of the day. The literature reports that families are a very important resource for patients since they manage to relieve the stress caused by critical illness, and their support is essential for recovery.³⁷ For all these reasons, a care approach is essential in which nurses include families in the care of patients and guide them during the process.³⁸ Furthermore, recognising the family as the central axis of care actions favours the humanisation of Intensive Care Units.³⁹

Finally, comments related to environmental aspects are widely described in the literature. Environmental noise is one of the most frequent causes of complaints from patients and families.^40–42 Promoting the culture of silence in the ICU would help improve the level of care satisfaction. Vulnerability is the result of the physical factor and the psychological-mental aspect, and silence could be a key factor in the degree of perception of the comprehensive well-being of the person-patient and of the professionals who carry out their care tasks in the ICU.³⁷

This research has methodological limitations. The study was carried out in a single centre with specific characteristics, making it difficult to generalise the results obtained. Most patients had a stay of 24 h. This could have influenced the patient's perception, with them giving the same answers to all the items without much detail. It is also possible that dissatisfied patients did not complete the questionnaire. Additionally, there may have been a survival bias because patients who died obviously could not be included in the study. Conducting multicentre research studies using the same assessment instrument in patients with stays longer than 24 h would therefore be advisable.

Conclusion

Patient satisfaction with nursing care in the intensive care unit was high with respect to the global score and each of its factors. Age, sex and degree of recovery significantly influenced their perception. The patients, in their comments, mentioned aspects of the nurse-patient relationship, the professional practice environment and the nature of the ICU. The professional practice model incorporated in the institution can enhance these results.

Conflict of interests

The authors declare that they have no conflict of interests.