Emergency (****); * (*): *-* This open-access article distributed under the terms of the Creative Commons Attribution Noncommercial 3.0 License (CC BY-NC 3.0). Copyright © 2015 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com 103 Emergency (2015); 3 (3): 103-108 ORIGINAL RESEARCH Brief Emergency Department Patient Satisfaction Scale (BEPSS); Development of a New Practical Instrument Mohammad Atari1*, Maryam Atari2, 3 1. Department of Psychology, University of Tehran, Tehran, Iran. 2. Faculty of Management, University of Tehran, Tehran, Iran. 3. Quality-Improvement Office, Moheb Hospital, Tehran, Iran. *Corresponding Author: Mohammad Atari; Department of Psychology, Faculty of psychology and educational sciences, University of Tehran, Jalal Ale-Ahmad Bridge, Tehran, Iran. Tel: + 00989126363263; Email: Atari@ut.ac.ir Received: October 2014; Accepted: December 2014 Abstract Introduction: Methodologically correct assessment of patient satisfaction (PS) plays a crucial role for quality-im- provement purposes. Evaluation of Iranian literature on emergency department’s PS resulted in an emerging need for developing a new instrument with satisfactory psychometric properties. The present study, aimed to develop and initially validate a scale to measure PS in emergency departments. Methods: A sample of 301 patients was selected in 2014 from two hospitals in Tehran. A pool of 24 items was prepared for administering. An item analysis was conducted to evaluate the quality of each item. Validity and reliability of the scale were evaluated. The data were analyzed using SPSS. Results: Item analysis and exploratory factor analysis yielded in a 20-item scale in five domains named emergency department staff, emergency department environment, physician care satisfaction, general patient satisfaction, and patient’s family’s satisfaction. Validity and factor structure of the scale were re- ported satisfactory. Reliability coefficients of the domains ranged between 0.75 and 0.88. Conclusion: The findings of the present study provided evidence for psychometric properties of a newly developed scale for PS assessment in emergency departments. Five underlying components of PS were found in the item pool. In sum, this scale may be used in research and emergency departments to measure PS. Key words: Satisfaction, patient; healthcare quality; departments, emergency; reliability and validity; psychometrics Cite this article as: Atari Mo, Atari Ma. Brief emergency department patient satisfaction scale (BEPSS); development of a new practical instrument. Emergency. 2015;3(3):103-8 Introduction: atient satisfaction (PS) is the measure of quality in healthcare perceived by patients and roots in dif- ferent complicated factors (1). Several factors should be coordinated with each other to make an ap- propriate condition for developing and improvement of PS with observing patient's rights in all aspects (2). This topic deserves attention because it is broadly a worthy goal and is a potentially important mediator for a range of outcomes. Satisfied patients are statistically more compliant with their medical instructions, suggesting that satisfaction may be an important component in pro- moting health and well-being (3-5). Satisfaction may also directly affect the financial viability of an institution by influencing consumer choice in the future. Moreover, it is a highly valuable factor for quality-improvement pur- poses which is gaining momentum in Iran as well as other countries (6). These factors have led to a prolifer- ation of studies on PS over the last years (7). Although the field of emergency medicine is comparatively new in Iran, it has not been neglected in the PS research. How- ever, like the larger PS body of literature, many of the existing emergency department (ED) PS studies have se- rious methodological flaws, which has led to inconsistent and, at times, contradictory conclusions (7). In Iran, many studies have utilized questionnaires in order to measure PS (8-12); however, no specially designed scale for ED was found reporting satisfactory psychometric properties. Studies that utilize such scales have the risk of acquiring limited or inconsistent data (7, 13). As a re- sult, the present study aimed to develop and initially val- idate brief emergency department patient satisfaction scale (BEPSS). Methods: Study design and setting Considering the body of literature, effective items in PS evaluation were extracted in a valid and reliable manner. All items aimed to measure a specific aspect of PS. The P This open-access article distributed under the terms of the Creative Commons Attribution Noncommercial 3.0 License (CC BY-NC 3.0). Copyright © 2015 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com Atari et al 104 preliminary battery of items was then checked for con- tent by a panel of experts including two hospital manag- ers, two quality-improvement officers, one physician, and one psychometrics professional. The aforemen- tioned panel of experts confirmed the face validity of each item. It was then modified to fit the current Iranian needs and resources. The Items were categorized into seven major domains of admission, nursing, physician care, environment, patient’s family, waiting time, and general satisfaction. Authors evaluated the content va- lidity of the instrument in the final step of scale develop- ment as well as initial steps. Reviews were used to eval- uate if the instrument covers required aspects of ED pa- tient satisfaction (7, 11). Item selection: Exploratory Factor Analysis (EFA) was performed in or- der to identify underlying components of the instru- ment. A broad item analysis was conducted prior to EFA (14). In this step, items’ exclusion criteria were set as: (a) missing more than 15% of data (b) having inappropriate indices of skewness and kurtosis and (c) inappropriate cross-loadings in EFA. Components were rotated using the varimax procedure and loadings under 0.4 were sup- pressed. Items with double loadings were categorized considering their contents and conceptual frame of work. Each item was scored from four (complete satis- faction) to one (complete dissatisfaction) as the re- sponse option was provided in a 4-point scale of Likert sort. No reverse scoring was required. Total ED patient satisfaction score was calculated by summing all the items’ scores. Cronbach’s alpha coefficient was calcu- lated to assess the internal consistency of each domain and total scale as a measure of reliability. Initial validation: 301responders were consecutively recruited from two hospitals in Tehran, summer of 2014. All participants were given final approved questionnaire by the panel as well as demographic questions. Questionnaires with more than five missing values were excluded. De- mographics consisted of respondent (patient/family), post-examination status (released/hospitalized/else), age, sex, time of admission, delay before admission (waiting time), and educational level. Demographic questions were developed in line with the existing liter- ature and on an exploratory basis. The verbal consent of all participants was obtained before administering the questionnaires in the emergency department. Questions were read aloud by an assistant for the elderly. Moreo- ver, all respondents were assured of the confidentiality of their responses. Statistical analysis Data entry and analyses were performed in a blinded manner by staff members who were not involved in the process of data collection. Statistical analysis was per- formed using statistical package for the social sciences (SPSS) software (version 21.0; SPSS Inc, Chicago, Illi- nois). An EFA with principal components technique was performed. Kaiser-Meyer-Olkin (KMO) measure was cal- culated to evaluate sampling adequacy. Bartlett’s test of sphericity was also performed. Finally, one-way analysis of variance (ANOVA) and independent t-test were used to evaluate total satisfaction among different groups de- rived from demographic characteristics. The minimum value of KMO measure for adequacy of data matrix for factorability was considered as 0.6 (15). P<0.05 was de- fined as significant. Results: Considering the body of literature in PS evaluation, 32 items were extracted but the final questionnaire ap- proved by the panel consisted of 24 items. 301 full field questionnaires met the inclusion criteria and were en- tered in the validation analysis. Baseline characteristics of the responders are presented in table 1. Items’ de- scriptive information and results of item analysis are presented in Table 2. All items’ indices of skewness and kurtosis were within acceptable range. Therefore, no items were discarded in this step of analysis. Table 1: Baseline characteristics of participants Demographic characteristic Number (%) Respondent Patient 132 (43.8) Family 165 (54.8) Missing 4 (1.4) Post-examination Released 88 (29.3) Hospitalized 51 (16.9) Else 108 (35.9) Missing 54 (17.9) Sex Male 186 (61.8) Female 109 (36.2) Missing 6 (2.0) Waiting time (minute) Under 5 158 (52.5) 5-10 37 (12.3) More than 10 18 (6.0) Missing 88 (29.2) Educational level High school or lower 112 (37.2) Associate degree 38 (12.6) Bachelor’s degree 123 (40.9) Master’s or higher 19 (6.3) Missing 9 (3.0) Admission shift Morning shift 142 (47.2) Evening shift 45 (14.9) Night shift 6 (2.0) Missing 108 (35.9) Age (years) 53.2 ±18.1 This open-access article distributed under the terms of the Creative Commons Attribution Noncommercial 3.0 License (CC BY-NC 3.0). Copyright © 2015 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com 105 Emergency (2015); 3 (3): 103-108 EFA was performed on the 24 items with varimax rotation. KMO measure of sampling adequacy was 0.923. Since the minimum value of this measure for adequacy of data matrix for factorability is 0.6, the data matrix had the required assumptions for factor analysis. Bartlett’s test of sphericity was significant (P<0.001). Four items (3, 7, 9, and 19 in the 24-item version) were discarded in this step be- cause of inappropriate cross-loadings. Another EFA was performed on the remaining 20 items (KMO=0.925) using varimax rotation and fixed number of five domains (Appen- dix 1). These domains were respectively named as emer- gency department staff (EDS), emergency department en- vironment (EDE), physician care satisfaction (PCS), general patient satisfaction (GPS), and patient’s family’s satisfaction (PFS). After rotation, these domains accounted for 16.1%, 15.1%, 14.5%, 13.6%, and 11.4% of the total variance. Thus, 70.7% of the total variance was explained via these five domains. Results of EFA are presented in Table 3. The total alpha coefficient of the 20-item scale was 0.94. Relia- bility coefficients of domains are presented in table 4. One- way ANOVA and t-test detected no significant difference in satisfaction of patients differentiated by gender, education, post-examination status, and responding person (P>0.05). However, those patients who were visited with shorter waiting times were significantly more satisfied (F=10.267; P<0.001) as predicted (Table 5). Finally, the overall satis- faction score was inversely associated with waiting time (r=-0.295, P<0.01). Discussion: Following this study, brief emergency department pa- tient satisfaction scale (BEPSS) was developed to evalu- ate the PS. This scale involves 20 items that score 1 to 4 and are categorized in 5 domains (EDS, EDE, PCS, GPS, and PFS). EDs are confronted with challenging issues which may reduce the PS (16). The satisfaction of ED cli- ents cannot be achieved without research and an orga- nized way of assessment in the field (17). So, this topic has been considered by researchers for many years to find an appropriate worldwide scale, but the search still goes on (18, 19). Variety of cultural effective factors in different countries and even different area may be one of the reasons of limitation for using the current question- naires (20, 21). In this manner, considering the psycho- metric properties of PS is also the missing point. Thus, assessment of PS within emergency departments of Ira- nian hospitals was in need of a reliable and valid instru- ment (22). Translation of foreign tools without report- ing characteristics of the test runs two potential risks. Firstly, validity and reliability of such instruments is questionable within Iranian population. Secondly, cross- cultural differences may play a central role in perception of healthcare quality from the viewpoint of patients (23). Using unrelated instruments such as inpatient/outpa- tient satisfaction tools also runs the risk of low face and content validity (24). Therefore, a specific scale for Table 2: The results of item analysis Item* Number Mean (SD)** Skewness Kurtosis Statistic (SD) Statistic (SD) Q1 298 2.89 (0.36) -3.90 (0.14) 18.79 (0.28) Q2 300 2.88 (0.40) -4.24 (0.14) 21.20 (0.28) Q3 283 2.77 (0.49) -2.65 (0.15) 9.47 (0.29) Q4 297 2.91 (0.32) -4.49 (0.14) 27.03 (0.28) Q5 295 2.88 (0.38) -3.77 (0.14) 16.95 (0.28) Q6 280 2.84 (0.43) -3.36 (0.15) 14.50 (0.29) Q7 293 2.94 (0.29) -6.00 (0.14) 44.48 (0.28) Q8 270 2.74 (0.50) -1.92 (0.15) 4.06 (0.30) Q9 259 2.49 (0.62) -0.92 (0.15) 0.32 (0.30) Q10 289 2.83 (0.46) -3.04 (0.14) 9.93 (0.29) Q11 283 2.71 (0.55) -1.90 (0.15) 3.32 (0.29) Q12 275 2.68 (0.59) -2.08 (0.15) 5.20 (0.29) Q13 274 2.72 (0.56) -2.10 (0.15) 4.63 (0.29) Q14 298 2.92 (0.36) -5.51 (0.14) 35.13(0.28) Q15 300 2.85 (0.42) -3.16 (0.14) 11.58(0.28) Q16 289 2.68 (0.55) -1.75 (0.14) 3.51 (0.29) Q17 276 2.92 (0.34) -4.92 (0.15) 29.16(0.29) Q18 266 2.91 (0.34) -4.46 (0.15) 25.25 (0.30) Q19 253 2.75 (0.58) -2.46 (0.15) 5.74 (0.31) Q20 295 2.77 (0.52) -2.62 (0.14) 8.08 (0.28) Q21 288 2.50 (0.71) -1.32 (0.14) 1.15 (0.29) Q22 295 2.81 (0.45) -2.57 (0.14) 7.61 (0.28) Q23 295 2.84 (0.42) -3.34 (0.14) 14.37 (0.28) Q24 299 2.80 (0.49) -2.97 (0.14) 10.74 (0.28) *: See appendix 1; **: SD= standard deviation. This open-access article distributed under the terms of the Creative Commons Attribution Noncommercial 3.0 License (CC BY-NC 3.0). Copyright © 2015 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com Atari et al 106 measuring PS in EDs seems essential as emergency pa- tients have complicated and specific situations. One of the problems associated with above-mentioned patients is a lack of time (25). Therefore, brevity should be con- sidered quite noteworthy. Additionally, adopting non- validated approaches of measurement is psychometri- cally problematic (13). This may also lead to inappropri- ate data and consequently wrong decisions in manage- rial levels. Measures of PS should adhere to basic princi- ples of psychometric measurement (15, 26). A study an- alyzed 195 studies of PS and concluded that authors demonstrated a poor understanding of the importance of core measurement properties required if a measure is to assess satisfaction with confidence (26). BEPSS made an effort to incorporate all effective factors of PS into an integrated measure in order to assess PS in emergency departments. Brevity is an extraordinary characteristic of the current instrument. This seems even more essen- tial considering the unusual situation of ED patients. It was illustrated that delay (waiting time) in ED is signifi- cantly associated with dissatisfaction of patients. Two delay-related items (20 and 21) are present in BEPSS, which are loaded in the General Patient Satisfaction (GPS) domain. Periodic assessment of PS, as a critical in- dicator in healthcare quality, seems centrally important. Strategies for quality-improvement purposes are made upon figures derived from the process of assessment. Widening the target population on a national level could have strengthened the results of the study; especially its generalizability. Since the primary properties of the scale are very good, this tool calls for further validation across the country. Conclusion: It seems that BEPSS, as a newly developed instrument with highly satisfactory psychometric properties, can be used for the assessment of emergency department’s pa- tient satisfaction. Acknowledgments: Authors would like to thank those patients who took part in this study. They also appreciate the cooperation of ED staff members of Moheb hospital in Tehran. Conflict of interest: None Funding support: None Authors’ contributions: All authors passed four criteria for authorship contribu- tion based on recommendations of the International Committee of Medical Journal Editors. Table 5: Correlation coefficients between domains and delay before admission Waiting time EDS EDE PCS GPS PFC Waiting time 1 EDS -0.319* 1 EDE -0.206* 0.662* 1 PCS -0.066 0.666* 0.511* 1 GPS -0.205* 0.704* 0.633* 0.710* 1 PFC -0.251* 0.730* 0.760* 0.531* 0.653* 1 * Significant at P<0.01 level. Emergency department staff (EDS), emergency department environment (EDE), physician care satisfaction (PCS), general patient satisfaction (GPS), and patient’s family satisfaction (PFS). Table 3: The results of exploratory factor analysis (rotated component matrix) Items Domains EDS EDE PCS GPS PFS 5 0.712 8 0.712 4 0.632 0.415 6 0.587 0.516 2 0.556 0.525 1 0.497 0.434 15 0.723 16 0.670 14 0.666 0.529 24 0.618 0.489 11 0.783 10 0.746 12 0.721 13 0.640 0.478 21 0.698 20 0.696 23 0.669 22 0.520 17 0.775 18 0.748 Corresponding loadings are bolded, emergency department staff (EDS), emergency department environment (EDE), physician care satisfaction (PCS), general patient satisfaction (GPS), and patient’s family satisfaction (PFS). Table 4: Reliability coefficients of five domains Domain EDS EDE PCS GPS PFS Question (N) 6 3 4 5 2 Alpha 0.88 0.75 0.87 0.84 0.87 *: N=Number, emergency department staff (EDS), emergency department environment (EDE), physician care satisfaction (PCS), general patient satisfaction (GPS), and patient’s family satisfaction (PFS). 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Nurses inform me about the remaining of the treatment 3. Nurses attended to me patiently 4. Nurses relieved me of the pain well 5. Admission staff guided me appropriately 6. The behavior of the admission staff was suitable Emergency department environment (EDE) 7. The environment of the emergency room was calm and quiet 8. Emergency room was well equipped 9. The environment of the emergency room was hygienic Physician care satisfaction (PCS) 10. The physician told me about my treatment course 11. The behavior of the physician was respectful 12. The physician’s explanation about the remaining of treatment was enough 13. The physician spent a sufficient time examining me General patient satisfaction (GPS) 14. The waiting time before seeing the doctor was appropriate 15. The waiting time before admission process was appropriate 16. I would recommend this hospital to my acquaintances 17. I am satisfied with the quality of services in the emergency room 18. The emergency room of this hospital is well functioning Patient’s family satisfaction (PFS) 19. The family of the patient are respected in this hospital 20. Family can spend an appropriate amount of time besides the patient Permission to use this measure is not required; however, seek permission if any item is modified for use in research. For each item, the following response scale should be used: 1 = completely disagree, 2 = mildly disagree, 3 = mildly agree, 4 = completely agree.