Improving Patient Satisfaction byAddressing Same Day Surgery Wait Times

Karen Freeman, RN, MSN, Sharon A. Denham, RN, DSN

Journal of PeriAnesthe

Wait times in same day surgery can create added stress to patientswho are already anxious. Perianesthesia nurses understand theimportance of patient satisfaction as they continually return tothe bedside, answer questions, and meet patients’ needs. Nursinginterventions to involve the patient and family can help decreasestress and dissatisfaction that occur when the patient is not up-dated about time changes. Defining quality care can be difficultwhen consumers and providers view things differently. Frequently,patients associate hospital stay satisfaction with the respect nursesdemonstrate for their needs. Timeliness regarding surgical times isan important aspect when meeting consumers’ care expectations.The purpose of this paper is to describe the problems patients mighthave with surgical wait times and to suggest ways to enhancepatient satisfaction.

Keywords: same day surgery, ambulatory surgery, patient satis-faction, wait times.

� 2008 by American Society of PeriAnesthesia Nurses.

Karen Freeman, RN, MSN, is a Graduate Student at Ohio

University, and a Staff Nurse in Same Day Surgery at Adena

Regional Medical Center, Chillicothe, OH; and Sharon A. Den-

ham, RN, DSN, is a Professor at Ohio University School of Nurs-

ing, Athens, OH, USA.

Address correspondence to Sharon A. Denham, RN, DSN,

Professor, Ohio University School of Nursing, E365 Grover

Center, Athens, OH 45701; e-mail address: denham@ohio.edu.

� 2008 by American Society of PeriAnesthesia Nurses.

1089-9472/08/2306-0004$34.00/0

doi:10.1016/j.jopan.2008.08.003

MRS MILLER ARRIVES at the Same DaySurgery unit to have a hysteroscopy. Eventhough her surgery is scheduled at noon, shehas been told to arrive two hours early. Uponarriving to the unit, a clerk greets and providesorientation to the cubicle, a small area thatcontains a bed, a bedside table, and two chairs.After disrobing and changing into a patientgown, Mrs Miller climbs onto the gurney andwaits for the nurse’s arrival. Vital signs aretaken, a physical assessment and healthhistory completed, and brief instructionsgiven. A check-off list is used to assure a safeenvironment for the surgical patient. The listincludes verification of nothing-by-mouth(NPO) status, allergies, correct patient nameand birth date, completion of appropriate labsand additional tests such as electrocardiogram,chest radiographs, and acceptance of bloodproducts. An anesthesia provider visits andcompletes a health history. Mrs Miller is of-

sia Nursing, Vol 23, No 6 (December), 2008: pp 387-393

fered an extra warm blanket and some maga-zines to read. She has been without food andwater since midnight. An intravenous line isstarted. Mrs Miller is now ready for surgery,so she lays back on the gurney and waits.A family member is allowed back into theroom to stay with her.

An emergency appendectomy ‘‘bumped’’ thecases in Mrs Miller’s OR. It is an extremelybusy day in Same Day Surgery, and the nurses

387

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have forgotten to tell Mrs Miller that she willnot be going to surgery at the time anticipated.About 45 minutes past her scheduled surgerytime, a nurse walks down the hall and MrsMiller’s family member motions to her. ‘‘Wethought she was going to surgery at noon,’’they say anxiously. ‘‘No one has been in togive us any information! She is thirsty and hun-gry. We feel like leaving and never returning toyour hospital.’’

Some patients are scheduled to arrive severalhours before surgery times, and it is notunusual to experience delays. As the patientsarrive for surgery, they are placed in an unfa-miliar setting, asked to remove their clothesand other personal items, and requested tosubmit personal information. Waiting in a sur-gical setting can induce additional stress forthose already nervous about surgery. Patientswill often say things such as, ‘‘I am scared todeath,’’ or ‘‘Hospitals always make my bloodpressure go up.’’ Arriving early allows nursesand anesthesia providers to complete assess-ments, laboratory tests, and determine safetystatus for surgery, but it can be a high anxietyand stressful experience for patient and family.

Many patients have significant stress levelsabout approaching surgeries and much ofthis anxiety may be largely related to nursingcare expectations.1 Some patients are nervouswhen scheduled for surgery, a fact that can beclinically verified by higher-than-normal bloodpressures and pulses.2 Although it is debatablewhether a surgical procedure should be can-celled because of an apparent hypertensivesituation, it seems that modern anesthesia pro-vided by a skilled anesthetist provider offerssufficient perioperative cardiac protection tomake surgery cancellation unnecessary undermost circumstances.3

Same day surgeries can produce high anxietylevels because patients have had limited orien-tation to the surgical environment. Althoughsame day surgery procedures have greatly im-proved over time, far less attention has been

given to patients’ emotional or psychologicalneeds. Research with patients undergoingminor gynecological surgery has indicatedthat persons have varied coping styles andalso different needs for preparatory informa-tion.4 The process of surgical intervention isan extremely anxiety-provoking experiencefor some patients, and this stress can impederecovery and sometimes cause adverse physio-logical changes.1 Fortunately, researchers havefound that distraction or an intervention suchas music can be helpful in reducing perioper-ative anxiety.5,6 Patient anxiety can be causedby uncertainties about anesthesia, the opera-tion, pain and discomfort, unconsciousness,and the wait time before surgery.7 Thus,nurses that pay attention to this presurgicalanxiety can likely assist to reduce it.

Quality Service and PatientSatisfaction

Confusion can occur when patients andnurses try to differentiate between patient sat-isfaction and quality care. Poor care qualitycan certainly lead to customer dissatisfactionand lost business,8 thus measures of patientsatisfaction should be closely linked with de-fined measures of quality in patient care.1 De-fining quality is sometimes difficult becauseproviders and consumers often view thiscare from different perspectives.9 When pa-tients describe quality of care, they often placegreater emphasis on aspects of interpersonalcare such as staff responsiveness or perceivedadequacy in having their unique care needsmet, whereas health care providers sometimesrefer to their perceptions of sufficiency inpatient treatment and level of clinical compe-tency as quality.9 The respect and interper-sonal care nurses provide is often consideredby patients when they indicate levels of satis-faction. In contrast, nurses may view qualityin terms of how well they believe patientshave been treated clinically.9

Patients enter a health setting with the expecta-tion that they will be treated as unique

IMPROVING SAME DAY SURGERY WAIT TIMES 389

individuals, with prior history and circumstancesrespected.10 Patients perceive quality in terms ofstaff responsiveness to their needs, such as ser-vice delivery, staff attitudes, environmental fac-tors, respect or courtesy demonstrated, andlevels of communication. Timeliness of nursesresponses to perceived needs may be construedas care quality. Thus, nurses who respondquickly and show respect for patient or familyconcerns may be viewed as more understand-ing and caring, and this response can lead tohigher levels of patient satisfaction.

Care delivery should be needs based and indi-vidualized, with the emphasis on human inter-action and communication. Nurses that havepride in their work and are happy completingtheir jobs are more likely to provide care ser-vices that result in greater levels of customersatisfaction.8 When nurses treat patientswith respect and honesty and remain commit-ted to excellence, they experience fulfillmentbecause they have contributed to theirpatients’ well-being.11 With caring at the heartof nursing, patients greatly value the presenceof the nurse.12 A therapeutic patient relation-ship involves listening and addressing specificneeds. Simple measures such as providingregular updates, reports of timely information,careful explanations of care aspects, attentive-ness to needs, and reassurance that demon-strates genuine interest and concern are alsokey to patient satisfaction.13

Short contact time between patients and nurs-ing staff during an ambulatory care setting canlead to dissatisfaction. Nursing interventionsare a significant indicator of overall patient sat-isfaction with hospital services.1,9,10 Patientsin same day surgery settings are often unfamil-iar with surroundings, uncertain about howthe experience will proceed, and have ques-tions that need to be answered. Professionalstaff may appear hurried and unapproachable.Looking at services through the customers’eyes provides valuable insights about howquality might be defined and measured insame day surgery settings.

Patients satisfied with a hospital experienceare more likely to use hospital services in thefuture, and this satisfaction can also be a deter-minant for whether discharge instructions arefollowed.9 Patients dissatisfied with care oftentell others, with the result as a negative effecton the health institution as a whole. In fact,a disgruntled customer may share his or herdissatisfaction with as many as 20 other peo-ple.9 In a qualitative study, researchers withonly six participants found that dissatisfactionwith hospital experiences is likely to beremembered over time. Even though thiswas a small study with six participants, itdoes suggest that hospital events have apti-tude to live long in one’s memory.14 After pa-tient discharge, problems such as pain,nausea, sore throat, or headache that occurand delay abilities to quickly return to fullfunction may cause dissatisfaction with sameday surgery.15 Patients are likely to return toa facility if they are satisfied with previousencounters.1,16 Satisfied customer ratingscorrelate highly with the nursing carereceived and whether the hospital experiencemeets expectations.9

The presence of a nurse has been found to bevaluable to patient recovery11; however,communication between patients and nursingstaff can have negative or positive conse-quences. Improved communication duringthe preoperative care phase provides animportant opportunity for a therapeutic inter-personal relationship between nurse andpatient, which in turn improves patients’perceptions and satisfaction.5 Nurse–patientencounters aimed at good communicationand therapeutic relationships work to estab-lish a bond that enables the nurse to identifypatient needs and enhances their hospitalexperience.

Some nursing behaviors have great potentialto create a positive nurse–patient environ-ment. Being attentive, giving verbal reassur-ance, explaining care aspects, and providingupdates on waiting times are often viewed as

390 FREEMAN AND DENHAM

caring and can reduce anxiety.13 ‘‘Confirming’’behaviors such as touching, maintaining eyecontact, standing near the patient whenspeaking in a low, clear voice, and avoidingtechnical language adds to patient satisfac-tion.14 Positively perceived nursing actionsare likely to result in more agreeable sameday surgery experiences and enhanced per-spectives about quality care and satisfaction.

Waiting Time

The length of waiting time is a primary com-plaint of patients in same day surgery, withpotential to induce additional stress for those al-ready nervous. For example, a patient might say,‘‘I was scheduled for noon, and it is already oneo’clock.’’ A call made to surgery to determinethe reason for delay can often provide an expla-nation. However, patients or families can havedifficulty understanding meanings of delays orreasons why some procedures take longerthan the allotted time. Unscheduled emergencysurgeries may also contribute to delays. Patientsand families can become more agitated and anx-ious as the wait time increases, and these waitscan create emotional distress, signal poorly or-ganized processes, and imply a lack of respectfor the patient.17,18 To consumers, these waitsmay imply that the care quality has fallen shortof expectations.

Waiting times associated with any care facilitycan have a significant relationship to patientsatisfaction.18 Waiting times longer than 15minutes have been rated as an importantfactor that may account for 94% of patientsatisfaction.17 Emergency departments appearto be most frequently studied regarding wait-time studies, because this is an area wherelong waits are expected. However, duringa hospital encounter, when a patient has a spe-cific appointment time, it may be viewed asa contract or commitment that the care pro-vider has made.18 Creative and supportiveinterventions during these waiting timescan be important in alleviating stress andimproving health outcomes.6 For example,

interventions such as schedule reorganizationchanges, patient flow modifications, or staff-ing changes may be important ways to reducesame day surgery waiting times.16 A con-cerned nurse may want to inform patientswho are new admissions to same day surgerydepartments about delay possibilities andassure that updates occur regularly as sched-ules change.

Limited evidence exists to propose optimalstaffing levels for same day surgery becausemost recommendations have been madebased on patient numbers, rather than onacuity of care.5 Working on a busy unit withminimal staffing creates challenging situa-tions. As nurses take assignment of arriving pa-tients who need admission care procedurescompleted, those patients who have beenreadied for an hour or more may begin tobelieve that they have been forgotten. Thereceipt of up-to-date information about waittimes can increase satisfaction about the hos-pital experience.18

Previous researchers show that a significantcause of dissatisfaction with care is deficientor lacking information.14 Nurses can assumethat information has already been given towaiting patients by someone else. The creationof explicit policies about persons responsiblefor updates, timing of updates, and methodsfor delivery of updates could reduce stress aspatients await their turn. Making sure that pa-tients clearly understand what to expect canreduce the situation’s ambiguity and is a keyfactor that influences clinical outcomes andpatient satisfaction.1

Perceptions About Wait Times

An important component of the wait time con-cern is perception of how surgery waitingtime is experienced. Innovative strategiescan effectively create an atmosphere wherecustomers are more satisfied as they wait.For example, interventions using music,soothing room colors, temperature control,

IMPROVING SAME DAY SURGERY WAIT TIMES 391

and pleasing furnishings are ways to enhancepatient satisfaction.18 Other suggestions in-clude the availability of current magazines,play areas for children, TVs, and hand-heldgames in waiting areas that assist families to re-lax as they wait. By manipulating environmen-tal factors, attempts are made to make delaysfeel shorter, while friendliness and appropri-ate social interactions can divert focused atten-tion away from time consciousness.

Consumer satisfaction decreases as percep-tions about the length of time waiting con-tinues.18 Ideas about time perception mustbe acknowledged. When patients arrive atthe ambulatory setting, they expect a processto start that will take them through the surgi-cal experience in a safe, efficient, and timelymanner. Even if nurses view surgical experi-ences as commonplace, patients view thesetimes as distinctive or extraordinary. Patientsmay be ill-informed about what to expect,have little knowledge about what transpiresin a hospital experience, and may concentrateon fears about events before, during, and afterthe procedure. Answering questions andaffirming concerns creates opportunities forpositive human encounter experiences withtherapeutic potentials, outcomes that canreap positive rewards in terms of satisfied cus-tomers. When dissatisfaction occurs regardingsurgery wait time, it conveys a message thatthe patient’s time is less valuable than thecare provider’s time.18

The nurse and patient have some different, butalso some common, objectives and can usegood communication techniques to quicklydevelop a relationship that helps both obtaintheir goals.12 Because of the limited time spentwith patients in same day surgery settings,barriers for developing therapeutic relation-ships between nurse and patient exist.The value of sustaining positive interactionswith patients should not be underestimated.12

Brief care and the routine nature of many sameday surgery procedures can create obstaclesto meaningful patient encounters. Therapeu-

tic communication provides opportunitiesto give patients pertinent information andeducation to maximize the same day surgeryevent. Information given preoperativelyshould include what to expect during theirstay, what is needed upon discharge, andfollow-up instructions, with reinforcement ofthis information done postoperatively.1,13

Empowerment During Wait Times

Family members also play key roles whenproblems linked with same day surgery waittimes are considered, and they are often theones who approach the desk to inquire aboutdelays. Families may have arranged time offfrom work or other life engagements to whichthey are expected to return. Collaboration andinclusion of family members in updates aboutwait times will enhance the respectfulrelationship between nurse and patient.19

Although same-day surgery nurses are oftenbusy, they should also be responsive to familyconcerns and address emotional clues, anxi-eties, and psychological stresses.

Encouraging patient and family participationshows respect and empowers them to beinvolved and clarify reasons for delays. Aclient-centered care approach that valuesand respects persons and uses empowermentthat respects independence, self-determina-tion, and participation in decision-makinghas great potential to increase perceptionsabout quality of care and satisfaction withthe same day surgery experience.20 Patientor client-centered care responds to eachpatient’s wants, needs, and preferences; givesopportunities to be informed and involved inmedical decision-making; and supports thoseattending to patients’ physical and emotionalneeds.21

We have found that use of an empowermentapproach in a community-based same daysurgical unit had positive effects. Patients care-fully instructed to use their call light if theythink that their wait time is too long seem

392 FREEMAN AND DENHAM

happily surprised with the control providedwith this simple action. Use of a small dryerase board mounted in each same day surgerycubicle is used to write the primary nurse’sname and the expected surgery time. Thisempowers the patient by informing themwho to call and assures them that the nurseunderstands the schedule for the procedure.Although a literature review failed to produceresearch evidence about the effectiveness ofthis approach, we identified success usingthis method. Interventions such as keepingthe patient informed, updating on waitingtimes, providing information, explaining careaspect, being attentive, taking time to listen,and providing verbal support are importantinterventions that help establish a valuablenurse–patient relationship.13 Communicationbetween the provider and the patient has a sig-nificant impact on patients’ overall hospitalexperience.22 Besides a positive surgical out-come, what matters to most patients andfamilies is the staff interaction and communi-cation aspects of their hospital encounter.23

Stress manifests itself physiologically, psycho-logically, and socially. Same day surgery experi-ences create an uneasy period when worriesand fears about the upcoming surgery mayintensify anxious feelings. Creative and com-passionate actions by nurses during theseuncomfortable waiting times have beenshown to be important in ways to decreasestress and improve health outcomes.6 Asmentioned earlier, a significant number of pa-tients express moderate to extreme anxiety

before undergoing surgery, and better in-formed patients tend to exhibit lower anxietylevels.1,13 Satisfaction tends to be higher whenpatients believe they have been kept up todate on expected wait times.18 Giving patientsand families access to information is a valuedway to enhance their sense of control and em-power them to be active participants in thesurgical experience.

Conclusions

Waiting is not an activity well received intoday’s fast-paced society, but it is an impor-tant one for nurses to consider. Understandingthe way one values time can influence rela-tionships and assist the same day surgerynurses to respond effectively to patient andfamily anxieties. Nurse reflection about thevalue of patients’ time is a first step to posi-tively alter the ways in which preoperativeinteractions occur. Second, clear communica-tion at the admission about the expected surgi-cal time and potential problems that mightlead to delays provides useful information aspatients wait to be wheeled into the surgicalsuite. Third, empowerment or use of a con-tract that establishes the nurses’ intent to seethat the patient goes to surgery at the sched-uled time, and to negotiate an action plan foruse if a delay occurs, can be helpful. Proactivenursing actions can reduce stressors associ-ated with wait times and positively impactperceptions of quality care and patient satis-faction.

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