Development and evaluation of a
questionnaire to assess patient
satisfaction with chemotherapy nursing
care
JohnSitzia Mphil, BA,
Researcher,Worthing
Nursing Development
Unit, Worthing Hospital,
Lyndhurst Road,Worthing
BNII 2DH, UK
Nell Wood PhD, MA,
Senior Lecturer. Health
Sciences ResearchCentre.
Chichester Institute,
College Lane,Chichester
POI9 4PE,UK
Correspondence and
offprint requests to:
John Sitzia
EuropeanJournalofOncologyNursing3(3),126-140 © 1999HarcourtPublishersLtd
John Sitzia, Neil Wood
This paper reports the development and p s y c h o m e t r i c t e s t i n g of an i n s t r u m e n t t o assess
p a t i e n t satisfaction w i t h o u t - p a t i e n t c h e m o t h e r a p y t r e a t m e n t , the Worthing
Chemotherapy Satisfaction Questionnaire (WCSQ). Content validity was established in
t w o stages.The f i r s t stage involved a preliminary identification of themes and the
development of a patient self-report questionnaire using a 4-step approach.The second
stage involved an analysis of quantitative and qualitative data from 173 completed
questionnaires. Construct validity was evaluated using a 3-step approach, including
confirmation of a homogenous factor using Cronbach's alpha (~), and discriminance
procedures to examine differences in the satisfaction o f c o m p l i a n t and non-compliant
patients. Reliability of the questionnaire was assessed by determining the internal
consistency of subscales using Cronbach's (~.The results indicate t h a t the WCSQ displays
acceptable reliability and validity. Analyses o f t h e findings f r o m 173 patients suggest t h a t
there exist six distinct components of satisfaction w i t h chemotherapy care: interpersonal
aspects of care, technical aspects o f care, p a t i e n t education, m u l t i d i s c i p l i n a r y t e a m w o r k ,
treatment environment and hospital accessibility. © 1999 Harcourt Publishers Ltd.
Keywords: patient satisfaction, psychometric evaluation, nursing care, chemotherapy, oncology, day
care
Entwicklung und Evaluation eines Fragebonges zur Erhebung der Patientenzufriedenheit mit der pflegerischen
Versorgung bei Chemotherapie
Diese Arbeit berichtet Liber die Entwicklung und psychometrische 0berprLifung eines Instrumentes zur
Messung der Patientenzufriedenheit mit der ambulanten chemotherapeutischen Behandlung, des 'Worthing
Chemotherapy Satisfaction Questionnaire (WCSQ)'. Die inhaltliche GLiltigkeit wurde in zwei Phasengesichert.
Die erste Phase beinhaltete die vorl~iufige Identifikation vonThemen und, in 4 Schritten, die Entwicklung eines
Fragebogens, der von Patienten auszufiJIlen ist. Die zweite Phase beinhaltete die Analyse der quantitativen und
qualitativen Daten yon 173 ausgefiJIIten Frageb6gen. Die Konstruktvalidit~it worde mit einer 3-schrittingen
Vorgehensweise Liberpr~ift, die sowohl die Best~tigung eines homogenen Faktors mittels Cronbachs (als such
Verfahren, um Unterschiede in der Zufriedenheit yon kooperativen und nicht-kooperativen Patienten zu
ermitteln, beinhaltete. Die Reliabilit~t des Fragebogens worde durch die Ermittlung der inneren
0bereinstimmung der Sub-Skalen mittels Cronbachs (iJberpruft. Die Ergebnissezeigne, dab der WCSQ eine
akzeptable Reliabilit~it und Validit~it aufweist. Die Analyse der Ergebnissevon 173 Patienten deuten darauf hin,
dab es sechs unterschiedliche Komponenten der Zufriedenheit mit der Pflege bei Chemotherapie gibt:
zwischenmenschliche Aspekte der Pflege, technische Aspekte der Pflege, Patient enschulung, multidisziplin~ire
Teamarbeit, Umfeld der Behandlund und Erreichbarkeit des Krankenhauses.
Desarrollo y evaluaci6n de un cuestionario para valorar el nivel de satisfacci6n del paciente que recibe cuidados de
enfermeria al tratarse con quimioterapia
Este articulo muestra el desarrollo de un test psicom~trico utilizando una escala para valorar la satifacci6n del
paente que recibe quimioterapia en Hospital de Dia, el cuestionario utilizado fu el Worthing Chemotherapy
Satisfaction Questionnaire (WCSQ). La validez del contenido fue extablecida en dos etapas: la prlimera envolvla
una identiflcaci6n preliminar de los temas y dl desarrollo del cuestionario personal entregado al paciente, usando 4
puntos. La segunda fase envolvia un an~lisis cuantitativo y cualitativo de los datos recogidos de 173 cuestionarios
 Development and evaluation of a questionnaire to assess patient satisfaction 127

completados. La validez constructiva fue evaluada usando 3 pasos, incluyendo la conflrmaci6n de un factor
homog~neo usando Cronbach's alpa (~), y los procedimientos de eliminaci6n para examinar las diferencias en la
satisfacci6n bas~ndose en los pacientes complacientes y los no complacientes. La fiabilidad del cuestionario rue
evaluada para deteminar la consistencia interna de las subscalasusando Cronbach's alpa. Los resultados indican que
el WCSQ es un cuestionario v~lido y flable. El An~lisis de los resultados sacados de los 173 pacientes sugieren que
existen seis componentes distintos de satisfacci6n en Io referente a los cuidados ofrecidos en quimioterapis"
aspectos interpersonales de los cuidados, aspectos t~cnicos de los cuidados, educaci6n del paciente, equipo
multidisciplinar, ambiente en que se da el tratamiento y la accesibilidad al hospital.

INTRODUCTION care, the Worthing Chemotherapy Satisfaction

Patient satisfaction research is widely recognized
as an important approach to understanding
patients' experiences of care and to documenting
patients' views for the purposes of service
evaluation (Bond & Thomas 1992, Idvall et al
1997). Several hundred satisfaction reports are
published each year from a wide range of health-
care contexts (Sitzia & Wood 1997). However,
despite the significance of cancer and cancer care
in Western society, and despite the fact that more
than half of all patients with cancer receive
cytotoxic chemotherapy (Parkin et al 1993, Otto
1994), few have specifically addressed patient
satisfaction with chemotherapy care (Sitzia &
Wood 1998).
This lack of research activity perhaps reflects
an assumption on the part of health profes-
sionals that patient 'satisfaction' is irrelevant in
the face of the gravity of the disease and the
curative or palliative benefits of chemotherapy.
However, in addition to providing invaluable
insights into the care process and involving
patients in service evaluation, patient satisfaction
is important in the context of compliance. The
'optimal' cure requires a compliant patient;
however, an estimated 15% to 20% of patients
either refuse chemotherapy or drop out during
the treatment course (e.g. Moliterni et al 1991).
Importantly, it has been found that compliance
behaviour is influenced by cancer patients'
perceptions, rather than actual health status
(Given 1991). Other studies confirm that com-
pliance has much to do with the supportive
environment, patient-professional communica-
tion and patient satisfaction (Richardson et al
1988, Ellis 1991).
In recent years, the mounting emphasis on
evidence-based practice has led to the develop-
ment of a plethora of instruments to assess many
aspects of cancer care. It is increasingly accepted
that any assessment instrument must demon-
strate validity and reliability, as exemplified by
instruments concerned with assessment of
health-related quality of life (e.g. McQuellon
et al 1994, Ferrell et al 1995, Wyatt et al 1996,
Osoba et al 1997). This paper describes the
development and evaluation of a questionnaire
to assess patient satisfaction with chemotherapy
Questionnaire (WCSQ) (reproduced in Appendix
1). The study aimed to demonstrate a thorough
and yet practicable strategy to instrument devel-
opment and testing.
The purpose of instrument testing is to show,
to as large a degree as possible, that instrument
measures relevant variables and that measure-
ment is objective. Objectivity in measurement is
basic to all research and has two elements:
reliability and validity (Streiner & Norman 1989,
Hinds et al 1990). Reliability testing aims to
demonstrate that the instrument is measuring
something in a consistent and reproducible
manner. Validity testing aims to determine
whether or not the findings reflect reality. There
are two distinct aspects of validity. The first in
'content validity' which is concerned with
whether the instrument covers the content area
satisfactorily. The second is an objective mea-
surement of the accuracy of the instrument. This
may be achieved by comparing the results from
the new instrument to those from another
validated instrument. This test is referred to as
'criterion validity'. Alternatively, if no suitable
instrument exists, results from the new instru-
ment may be predicted using a research-based
hypothesis. This test is known as 'construct
validity'. This paper is structured around distinct
aspects of development and testing: content
validity, construct validity and reliability.
METHODS
Content validity
It is widely believed that a patient's experience of
care may be broken down into an number of
aspects of care, and furthermore that the patient
discriminates between each aspect when rating
his or her satisfaction (Fitzpatrick 1984, Rubin
1990, Williams & Calnan 1991). The identifica-
tion of these different 'components' of care is
central to the accuracy of satisfaction data.
'Content validity' is an approach to ensuring
that the instrument contains questions on each
component which is important to the patient's
decision on satisfaction; if the identification of
components is faulty or if a component is
EuropeanJournalof OncologyNursing 3 (3), 126-140
 118 EuropeanJournalof OncologyNursing
omitted then the instrument may be regarded as
invalid and, therefore, the results meaningless
(Mishel 1989). Content validity should also
examine the viability of the scale used. Content
validity of the WCSQ was approached in two
stages.
Item generation
A multilateral strategy for item generation is
desirable. Common elements in this strategy
include a literature review, consultation with
patients and peer review. Item generation by
health workers is also used, but this strategy
disregards evidence that patients and providers
often have very different perceptions of which
components are important to quality of care
(Donabedian 1980). Well-designed studies use a
combination of qualitative and quantitative
approaches (Carter 1984, Field & Morse 1985).
Item generation for the WCSQ consisted of
three elements:
1. Literature review
2. Consultation with patients via interview and
written contributions
3. Content analysis of data from stages 1 and 2,
with emergent themes used to develop
question items.
Item testing
Three tests of the draft instrument were made:
1. A pilot stage is useful in supporting validity
(Sapsford &'Abbott 1992). Two pilot studies
were carried out
2. The item formats were evaluated to ascertain
whether or not the whole range of possible
values was being used
3. Response patterns were examined to ascer-
tain whether or not separate, identifiable
'components' did indeed exist.
Identification of components used responses
from 173 completed WCSQ questionnaires.
Principal components analysis, as exemplified
by Abramowitz et al (1987) and Baker (1990),
was used for the analysis of quantitative date
(Kline 1993). Qualitative data were analysed
using a constant comparative method of content
analysis, as exemplified by Tishelman (1994) and
Astedt-Kurki and Koponen (1994). The aim of
this analysis was to produce a systematic
recording of themes that appeared in the data,
and to link the themes together using a category
system. Qualitative data analysis followed sev-
eral stages. First, the text was read and notes
made on general themes. There then followed
several phases of data coding. Each sentence of
text was regarded as a 'text unit'. Each text unit
was first assigned to one or more of the general
themes. All text for each theme were then read,
and broad categories (sub-themes) identified.
EuropeanJournalof OncologyNursing 3 (3), 126-140
Each text unit was then coded again and
assigned to one or more categories. The process
was then repeated to identify and code text by
sub-categories. The process continued until no
more sub-categories could be identified. The
resultant structure was then examined to ensure
that categories and sub-categories were relevant
to themes, and in order to remove similar or
repetitious categories. SPSS software was used
for analysis of quantitative data, QSR NU-
DoIST software for analysis of qualitative data.
Construct validity
It was not possible to approach validity of the
WCSQ via the criterion method as (1) no valid
instrument measuring the same variables could
be found, and (2) the theoretical correlation
between dimensions of satisfaction was unknown
in the chemotherapy context. The construct
approach to validity testing was therefore used.
Demonstration of construct validity uses a 3-
stage process, with a variety of techniques
available for each stage (Mishel 1989). The test
requires a hypothesis, developed by linking the
attribute being measured to some other attribute.
Usually this hypothesis will examine the differ-
ence between two or more populations who
would be expected to have differing amounts of
the property expressed by the instrument. Stage 1
of the test involves identifying the variables
related to the concept; stage 2 involves establish-
ing from research the extent to which the
variables measure the concept; stage 3 involves
performing studies to determine the extent to
which the items produce the predicted results. If
the expected relationship is found, then the
hypothesis and the measure are sound; if no
relationship is found, the fault may lie with either
the construct or the instrument (Streiner &
Norman 1989).
Development of the hypothesis
Construct validity was tested using the hypoth-
esis that those patients who prematurely with-
draw from chemotherapy at their own request
due to severity of experienced side-effects will be
less satisfied with their care than other patients.
Withdrawal from chemotherapy may be seen as
the most extreme form of non-compliance.
A sample of 173 patients who completed the
WCSQ were rated by the investigators and
nursing staff as 'compliant' or 'non-compliant'.
Non-compliance was defined specifically as 'pre-
mature cessation of chemotherapy at patient's
request due to severity of experienced side-
effects'. Non-compliant patients were identified
through examination of nursing documentation.
Five patients (3 % of the sample) were identified
as non-compliant. All were receiving 5-fluorour-
acil + folinic acid on a 'week per month' regime
for 6 months.
 Development and evaluation of a questionnaire to assess patient satisfaction
Stage 1 and stage 3 tests
Four questions relating to advice or support for
side effects were chosen to test construct validity.
For stage 1, responses from 151 participants
who completed all four questions were examined
to ensure that the four questions related to a
c o m m o n concept. Factor analysis is commonly
used for this purpose. However, factor analysis is
unsuitable for analysis of a very small number of
variables. Cronbach's alpha (00 was therefore
used. As with factor analysis, this test is based on
the assumption that it is reasonable to expect
that responses to questions addressing the same
underlying dimension should be correlated with
each other. Alpha is simply a calculation of the
average of the correlation's among all the items
entered into the test. Proposed benchmark values
for ~ range from 0.50 to 0.80 (Streiner &
N o r m a n 1989, Carey & Siebert 1993).
For stage 3, the difference in responses
between the 'compliant' and 'non-compliant'
groups were examined using the Student t-test
(for data from VAS items) and the Mann-
Whitney U test (for data from ordinal items).
Instrument reliability
There are two approaches to instrument relia-
bility: measurement of 'stability', using a test-
retest method, or measurement of 'internal
consistency'. Using a measure of correlations
between items. Internal consistency using Cron-
bach's ~ was the test chosen in this study as some
participants were involved in other research
studies during the period of data collection and
it was considered unacceptable to ask patients to
complete additional retest questionnaires.
Study site
The study site was Edburton D a y Ward in the
Cancer Care Unit at Worthing Hospital, UK.
The ward provides chemotherapy on an out-
patient basis for approximately 150 new patients
per year.
Study sample
Three discrete groups of patients were involved.
The first was a sample used for the process of
item generation. Nineteen patients were invited
to participate at this stage. This was not a
random sample; patients were selected to repre-
sent a cross-section of diagnoses, regimes and
familiarity with the ward. Patients were sent a
letter asking for comments on the service, either
via a written response or via an interview on their
next visit to the ward. Ten of these patients
provided data.
The second group was a sample of 21 patients
asked to complete the pilot questionnaire. The
first 21 patients to attend the ward in the pilot
129
period were asked to participate and none
refused. The third group consisted of 173
patients who completed the instrument during
the main study period (July 1994 to January
1996). This group included 20 patients used to
test the final version of the questionnaire via a
second pilot study. During the main study
period, 278 patients with a cancer diagnosis
received chemotherapy as a day case. Forty-three
of these patients did not form part of the study
population: 7 patients under 18 years of age, 6
patients under the care of another hospital who
visited solely for maintenance of an infusion
pump, and 30 patients who received mitomycin-
C treatment for cancer of the bladder. This last
group were excluded as (1) this is an intra-vesical
treatment, requiring no cannulation, and (2)
mitomycin molecules do not penetrate the
bladder wall and therefore the drug causes no
systemic side-effects.
Of the remaining 235 patients, 11 had taken
part in the first pilot stage and so were excluded
from the main study. A further 24 patients were
considered unable to participate due to their
state of health. Nursing staff considered these
patients too distressed and/or poorly - due to
disease or side-effects - to complete a question-
naire. Two hundred patients were therefore
eligible for data collection. Questionnaires were
distributed in two ways: (1) face-to-face, handed
by a nurse or the researcher to the patient on a
visit to the ward, with a pre-paid addressed
envelope to return the questionnaire; (2) by mail
to the patient's home address, including a pre-
paid addressed envelope and a covering letter. If
no response was obtained within approximately
a month, a second questionnaire was sent. Ten
patients did not receive a questionnaire due to
administrative oversight. Questionnaires were
distributed to 190 patients and 173 were
returned. The response rate for the main study
was 86% including 'missed' patients, 91%
excluding 'missed' patients.
Therefore, 204 patients in total participated in
instrument development and testing. There were
60 non-participants (10 missed, 26 non-respon-
dents, 'too ill'). To determine whether the study
sample was representative of the main study
population, differences in demographic and
disease characteristics of participants and non-
participants were tested using the chi-square test,
the Student t-test and the Mann-Whitney U test.
RESULTS
Study sample
Demographic and disease characteristics for
participants and non-participants are presented
in Table 1. 'Regime frequency' indicates the
EuropeanJournalof Ontology Nursing 3 (3), 126-140
130 EuropeanJournalof OncologyNursing
Characteristic
n 204
Age in years mean [standard deviation]
range
Gender female
male
Regimefrequency median days per month
Regimetoxicity high
medium
low
Diagnosis solid tumour
haematological
Non-compliant
Survived 6 months --
post-chemotherapy
n.s.: n o t significant
number of visits per month to the ward for
chemotherapy treatment. 'Regime toxicity' data
refer to a regime toxicity rating from 1 (low
toxicity) to 3 (high toxicity). There was only one
statistically significant difference between the two
groups: a greater proportion of participants that
non-participants survived for at least 6 months
post-chemotherapy (90% vs 58%).
One hundred and forty participants (69% of
participants) were receiving treatment for a solid
tumour: 85 breast, 41 colorectal, 11 ovarian
and 3 lung. The most common regimes were
cyclophosphamide + methotrexat 5-fluorouracil
(CMF) (66 participants, 32% of participants)
and single agent 5-fluorouracil (41, 20%).
Content validity
Item generation
A search of the MedLine and C I N A H L data-
bases was conducted using combinations of the
following subject headings: patient satisfaction,
consumer satisfaction, patient compliance, pa-
tient acceptance of health care, anti-neoplastic
agents, breast neoplasms, cancer care facilities,
out-patients chemotherapy (adjuvant), treatment
refusal, patient participation, oncology service
(hospital) and day care. The review revealed no
literature with a specific focus on satisfaction
with chemotherapy nursing care. Therefore, it
was necessary to examine satisfaction data from
related areas: day treatment services (e.g. Davis
et al 1988, Greenwood 1993, Sitzia et al 1996),
people with cancer but with no focus on
chemotherapy (e.g. Thompson 1989, Ansell
1992, Burton & Parker 1994), chemotherapy-
related patient education (e.g. Derdiarian 1989,
Fernsler & Cannon 1991, Ream & Richardson
1996), psychosocial implications of chemother-
apy treatment (e.g. Coates e t al 1983, Meyer-
owitz et al 1983, Dodd et al 1992), chemotherapy
documentation (e.g. JCCO 1994, Tanghe et al
EuropeanJournalof Oncology Nursing 3 (3),126-140
Participants Non-participants Te~ result
n(%) n(%)
60
56.1 [13.0] 58.0 [12.6] t = 1.0, n.s.
21-85 34-83
136 (67%) 42 (70%) 22 = 0.2, n.s.
68 (33%) 18 (30%)
2 2 U = 5303, n.s.
80 (39%) 18 (30%) ~2 =4.2, n.s.
84 (41%) 23(38%)
40(20%) 19 (32%)
140(69%) 33 (55%) ~C2= 3.2, n.s.
64 (31%) 27 (45%)
5 (2%) 2(3%) ~2 = 0.1, n.s.
183 (90%) 35 (58%) Z2 = 31.7.
p < 0.01
1994, Senior Smith & Richardson 1996), patient-
health professional communication (e.g. F i t z -
patrick et al 1992, Wilkinson 1992, Lerman et al
1993), chemotherapy side-effects (e.g. Johansson
et al 1992, Tierney et al 1992, Ward et al 1992,
Sitzia et al 1995) and nursing practice (e.g. Risser
1975, La Monica et al 1986, Reid-Ponte 1992,
Kadner 1994, Tishelman 1994, Hewison 1995).
Four issues were repeatedly highlighted: techni-
cal aspects of care, interpersonal aspects of care,
patient education and treatment environment.
During the period February to March 1994,
unstructured interviews were conducted with two
current patients by a non-nurse researcher.
Interviews took place in the ward waiting room
as patients awaited chemotherapy. In addition,
letters were sent to 17 former patients asking for
suggestions as to areas they considered worth
investigating. A number of themes were used as
prompts in both the interviews and letters: level
of information, waiting times, accessibility,
involvement of relatives or friends, post-treat-
ment support, satisfaction with technical aspects
of care, treatment environment, privacy, expec-
tations of chemotherapy, advice on side-effects
and possible improvements. Eight replies were
received. Several themes were highlighted in
addition to those identified through the literature
review. Accessibility, in terms of both hospital
accessibility and suitability of appointment
times, was poor for some patients. The issue of
treatment environment was also noted, particu-
larly regarding privacy. 'Approachability' of
medical and nursing staff was a central theme,
with the importance of interpersonal aspects
such as 'friendliness' or 'cheerfulness' repeatedly
indicated. The lack of time available for discus-
sion, level of information on completion of
chemotherapy and post-chemotherapy contact
were also commented upon. Table 2 lists the
themes which were identified via the literature
review and patient consultation process.
 Development and evaluation of a questionnaire to assess patient satisfaction 131

Difficulty parking at hospital Staff 'friendliness' Lack of space on the ward

Poor public transport to hosptial
Hospital transport system
Distress at seeing very ill patients
Lack of a patient support group
Waiting times on ward
Nurses' inattention to confidentiality
Appointment times
Problems in other departments
(out-patient clinics, pathology)
Nurses' medical knowledge
Staff 'cheerfulness'
Staff 'pleasant' or 'unpleasant'
Lack of time to talk to staff
Lack of information upon
completion of chemotherapy
Explanation of side-effects
Self-care for side-effects
Nursing care for side-effects
General atmosphere on the
ward (and effect on anxiety)
Pre-treatment anxiety
Level of information regarding disease
Level of information regarding treatment
Post-treatment support and follow-up
Involvement of relatives and friends
Cannulation/needle phobia
Provision of counselling/support support
'Approachability' of staff
Nurses' technical skills
Lack of privacy on the ward

Item testing patients to provide further comments on the

1. Pilot testing and evaluation of item formats
The WCSQ used a multidimensional approach to
satisfaction assessment using the identified
themes. The pilot instrument contained 50 items
covering the following dimension: demographic
variables, pre-treatment anxiety, service accessi-
bility, waiting times on the ward, treatment
environment, interpersonal nursing care, techni-
cal nursing care, patient information, physician
care, mutlidisciplinary care framework, an 'over-
all satisfaction' item, a question asking who
would be the patient's first point of contact for
information post-treatment and a prompt for
comments at the end of the questionnaire. WCSQ
items aimed to avoid presumption, lack of clarity
and ambiguity (Risser 1975, Baker 1991).
Twenty-one draft questionnaires were distri-
buted to patients receiving chemotherapy. All
were returned. The main problems identified
form the pilot stage responses concerned item
formats rather than content. In particular, 11
items which used a 100 mm Visual Analogue
Scale (VAS) to assess satisfaction produced very
skewed results, with 90% of responses falling in
the upper third of the scale. The anchor
statements for the scale were 'the worst care
possibly imaginable' and 'the best care possibly
imaginable'. In an attempt to elicit greater
distribution in responses, the anchor statements
were modified to 'standard N H S level of care'
and 'the best care possibly imaginable'. In add-
ition, four items which appeared to be duplicat-
ing other items were omitted, and patients'
comments prompted two items to be added.
The revised questionnaire was distributed to a
sample of 20 patients, none of whom had been
involved in the first pilot. Data analysis showed
that the amended items produced more variability
in response. The final questionnaire contained 48
items, of which 27 were subjective satisfaction
items. Most questions used either a 5-point
adjectival scale or a 100 m m VAS. The ques-
tionnaire contained four items which asked
treatment environment, Day Ward nursing care,
patient information, the hospital support frame-
work and an open 'general comments' question.
The questionnaire is reproduced as an Appendix.
2. Examination of components: quantitative data
Responses to 25 satisfaction items from 173
completed questionnaires were entered into a
factor analysis. The K-M-O value for the initial
matrix was 0.88. The Barlett value was 3111
( P < 0.0001). Principal components extraction
revealed the presence of six factors with an
eigenvalue greater than 1. These six factors
explained 71.5% of the variance. However, at
1.03, the eigenvalue for factor 6 was only barely
greater than 1, and this factor was therefore
excluded from the rotation. The five remaining
factors explained 67.3% of the variance. Since it
cannot be presumed that the five factors were
completely uncorrelated - indeed it would be
expected that they would correlate to some
extent - an oblique rotation was chosen.
Results from the analysis are presented in
Table 3. The items associated with each of the
five factors are listed with the loading to that
factor. The 'loading' coefficient indicates the
strength of the correlation between the item and
the factor; the minimum loading is 0 (i.e. no
correlation) and the maximum is 1. Loadings of
less than 0.5 have not been shown. The five
factors appear to be associated with the follow-
ing components: nursing care (both technical and
interpersonal aspects); patient education; treat-
ment environment; approachability of medical
and nursing staff; and hospital accessibility. Day
Ward nursing care was by far the strongest
factor, with an eighenvalue of 9.4. The mean
correlation for the five factors was 0.18. 'Nursing
care' and 'treatment environment' produced the
highest correlation (r = 0.34), while 'nursing care'
and 'hospital accessibility' produced the lowest
correlation (r = 0.04).
3. Examination of components: qualitative data
The total number of text units was 563. Five
EuropeanJournalof OncologyNursing3 (3),126-140
132 European Journal of Oncology Nursing

Factor Item Loading

Factor I: Nursingcare
(eigenvalue = 9.4, explaining 37.5% of the variance)
Nurses' reassurance and support 0.95
Nurses' awareness of side-effects 0.90
Nurses' having time to talk to you 0.89
Nurses' appreciation of your individual needs 0.86
Nurses' medical knowledge of your problem 0.86
Nurses' technical skill in giving chemotherapy 0.84
Help given in controlling side-effects 0.83
Explanation of procedures and treatment 0.82
Nurses' concern for your relatives/friends 0.79
Nurses' concern for privacy when giving treatment 0.74
Nurses' concern for privacy when discussing personal details 0.67
Factor 2: Patienteducation
(eigenvalue = 3.2, explaining 13%of the variance)
Information regarding chemotherapy 0.81
Information regarding diagnosis 0.72
Hospital support framework 0.67
Practical advice on side-effects 0.65
Advice on self-care whilst receiving chemotherapy 0.57
Factor 3: Treatmentenvironment
(eigenvalue = 1.8, explaining 7% of the variance)
Level of privacy when receiving chemotherapy 0.84
Being treated with other patients around 0.80
Waiting time on Day Ward 0.66
Chemotherapy appointment times 0.64
Factor 4: Approachabilityof medical and nursingstaff
(eigenvalue = 1.3, explaining 5% of the variance)
Approachability of consultants 0.72
Approachability of nurses 0.72
-rime to talk with staff 0.71
Factor 5: Hospital accessibgity
(eigenvalue = I.I, explaining 4% of the variance)
Transport to the hospital 0.72

broad themes emerged, each with several cate- appeared in the factor analysis. However, the
gories: nursing care, physician care, multidisci- qualitative data suggested that patients do
plinary teamwork in service provision at differentiate between 'technical' and 'interperso-
Worthing Hospital, patient information, and nal' aspects of care. Three further categories
treatment environment. Themes, categories and appear in the matrices: 'staff approachability',
sub-categories are presented as Figure 1. 'physician care' and 'multidisciplinary team-
The frameworks for components of care work'. The first two clearly overlap with the
derived from the quantitative data (Table 3) two 'direct care' components; it would seem
and the qualitative data (Fig. 1) are similar in appropriate in a classification of components of
several respects. Patient education and treatment satisfaction with a chemotherapy service to
environment appear as distinct components in regard these concerns as aspects of interpersonal
both classifications. Accessibility of the hospital and technical care. However, multidisciplinary
also appears a distinct, if weak, component. team work appears of distinct concern - this
Direct personal care clearly appears the strongest refers not to the quality of care provided by
component in each matrix. In the quantitative individual team members, but to the organiza-
data, responses to these 'direct care' items were tion of the service as a whole. Therefore, the data
strongly correlated and so a single strong factor suggest a classification of six components:
ICHEMOTRERAPYSERVICEI
I I
[ PHYS'C'ACARE FMEWORKAR i 'NFOR ON I I WARDENV
N I I ' ERD'Sc'PL' RONMEN'[
I INTERPERSONAL I l .EEMPATHY
ASS~RANCE
I ~SERV'CEOVE~L~I
I H ~ I
t PROGNOSIS I
REGIME/DRUGS I
t BUSY
PRIVACY
I
I
SIDEEFFECTSI I ;EMP,~THY' I I 'AttiTUDE' I SIDE EFFECTS I DESIGN }
CANNULATION [ REASSURANCE I TIMETOTALK TIMETOTALK I M 'DOVETAILING' I PROCEDURES I
PROCEDURESI I _ [ ~ G I KINDNESS
14 ~
J-J SENSITIVITY
]
I
POL,~NESS
CHEERFULNESS
H CONCERN I RELAXED
FRIENDLINESS

Fig, I.Themes and categories identified through content analysis of qualitative data.

EuropeanJournalof Oncology Nursing 3 (3), 126-140

 Development and evaluation of a questionnaire to assess patient satisfaction
interpersonal aspects of care, technical aspects of
care, patient education, multidisciplinary team-
work, treatment environment and hospital acces-
sibility. This classification was examined through
internal consistency analysis, described below.
Construct validity
Stage 1: Specification of items related to the
construct
The Cronbach ~ value for the four items was
0.77.
Stage 2: research evidence that the items
measure the construct
Chemotherapy side-effects are acknowledged as
a leading cause of discontinuation of chemother-
apy treatment (Hoagland et al 1983, Penta et al
1983, Olver et al 1986, Buccheri et al 1989, Given
1991, Morrow et al 1991, Ellis et al 1992, Tierney
et al 1992, Winningham et al 1994), as in
mucositis specifically (Bonadonna & Valagussa
1981). Non-compliance with medical care has
consistently been associated with patient dissa-
tisfaction (Fitzpatrick et al 1983, Thompson et al
t990).
Stage 3: tests to examine the predicated
difference in satisfaction between 'compliant'
and 'non-compliant' groups
Results are presented in Table 4. Question A
and B were VAS items (minimum=0, maxi-
m u m = 100); questions C and D were 5-point
ordinal scale items (minimum = 1, maxi-
mum-- 5). In both formats, higher scores indi-
cated higher satisfaction. The results for all items
were in the predicted direction; that is, the
satisfaction scores of the non-compliant group
were lower than the compliant group. For three
items, this difference was statistically significant.
The difference in one item did not reach
statistical significance. This question was not
answered by one non-compliant patient who
withdrew form treatment after o n l y one course
of chemotherapy.
Item
A: Satisfaction with nurses' 'awareness of side-effects
or other problems you may be experiencing'
B: Satisfaction with 'help given in controlling or
reducing side-effects'
C: 'Are you happy that you are given enough
practical advice on what to do about side-effects
when they occur?'
D" ~,re you happy that you are given enough advice
on how to look after yourself between courses of
chemotherapy, for example nutrition, skin care, oral care?'
*mean, **median; n.s.- not significant.
133
Reliability
Cronbach's ~ was calculated for each of the
components identified through the factor and
content analyses described above. Multidisciplin-
ary teamwork was excluded, as only one ques-
tion addressed this issue. Alpha values for the
other five components were as follows: inter-
personal care ~=0.89, technical care ~=0.92,
patient education ~=0.71, treatment environ-
ment ~ = 0.79 and hospital accessibility ~ = 0.35.
DISCUSSION
Commonly, assessment of the content validity of
a satisfaction questionnaire relies on subjective
judgement. This judgement may be informed by
several elements, such as literature review and
patient consultation. In this study, the steps
taken for the preliminary identification of themes
relevant to satisfaction with chemotherapy nur-
sing care would generally be regarded as a viable
approach to content validity if we use as a
benchmark the descriptions of content validity
procedures found in the satisfaction literature.
Many studies base content validity solely on a
review of previous satisfaction studies, which
assumes that previous attempts at item genera-
tion were thorough and accurate. This assump-
tion could not be made in the field of satisfaction
with chemotherapy nursing care. Only a handful
of studies specific to this area have been
reported; therefore it was necessary to draw on
related literature. This was pragmatic as a
considerable amount of research has been con-
ducted in areas which have implications for
chemotherapy patient satisfaction. An effort was
made to consolidate the review through a small
survey of local patients' opinions. This approach
was chosen in the light of evidence supporting
the use of different methods sequentially (i.e.
qualitative interview followed by quantitative
questionnaire) when attempting to first explore
and then measure a particular construct (Greene
Compliant Non-compliant Test result
average average
72.3* 18.6" t = 4.0
P < O.OI
72.7* 23.4* t = 3.7
P<0.01
5"* 2** z = 2.7
P<O.OI
4** 3** z = 1.8
n.s.
EuropeanJournalof OncologyNursing3 (3).126-140
 134 EuropeanJournalof OncologyNursing
et al 1989). Although these data appeared
broadly similar to the themes suggested by the
literature, and despite the fact that many useful
qualitative investigations have used a similar
sample size (e.g. Bluff & Holloway 1994, Dagnan
et al 1994, Nethercott 1994), the size of this
sample - 10 patients - was small. We now feel a
greater emphasis should have been placed on this
initial exploration of themes, and moreover, that
a primarily qualitative study of chemotherapy
patient satisfaction would be productive.
As noted in the introduction, the exploratory
stage was important in ensuring that all relevant
dimensions were included in the quantitative
assessment instrument. However, the WCSQ
also prompted respondents to provide comments
on various issues and prompted general com-
ments. This is a 'safety net' approach, designed
to allow patients to document concerns which
are not covered by quantitative items. The results
of the second stage quantitative and qualitative
analyses to examine content validity in this
instrument indicated that the questionnaire
included questions on all relevant dimension.
The revised VAS scales produced a fairly good
distribution of responses. Nevertheless, we feel
the use of the words 'standard NHS level of care'
for the bottom anchor on the scale was a bad
idea. First, this implies that a 'standard' level
exists and furthermore that all respondents know
what the 'standard' is; the former is untrue, and
so the latter is not only impossible to ascertain
but is also meaningless. Second, use of this
anchor allows no option for rating care that is
perceived to be lower than 'standard'. We would
advise that the original anchor statement ('the
worst care possibly imaginable') is used.
The consistency of questionnaire items was
assessed using Cronbach's e. Alpha values were
high for four of the five measurable dimensions.
The exception was 'hospital accessibility'. This
component consisted of only two quantitative
items, but nevertheless the poor correlation
between them was unexpected: 46% of the
sample stated that they had some sort of problem
getting to the hospital, but only 10% of these felt
that the hospital was 'very' or 'fairly' inacces-
sible. These items clearly require further investi-
gation and responses to them should be treated
cautiously. The a values for the four other
dimensions suggest these are reliable. It must
be noted that the 'internal consistency' approach
to reliability is regarded as weaker than the 'test-
retest' approach and an investigation of the
WCSQ using a stability procedure would be
worthwhile.
The theoretical nature of construct validity
and its association with less common statistical
analyses may be reasons for its unpopularity
among satisfaction researchers. However, the
test was found to be inherently logical. The
EuropeanJournalofOncologyNursing 3 (3), 126-140
hypothesis was soundly based on research
evidence, the Cronbach c~ analysis indicated that
a specific group of items relating to satisfaction
with side-effects management could be identified,
and the discriminance test showed a significant
difference in satisfaction levels between 'compli-
ant' and 'non-compliant' patients. However, the
validity of the test in this case is severely limited
by the low number of patients in the 'non-
compliant' group. It is impossible to determine
whether or not such a very small sample is
representative of the large 'non-compliant' po-
pulation, and so whether or not the test results
reflect a real difference between populations.
These results must be taken as tentative, and
further examination of the external validity of
the WCSQ undertaken.
Both the quantitative and the qualitative data
support the concept of patient satisfaction as a
multidimensional construct. Data reduction for
both sets of data revealed five components. The
two matrices were not identical, but this was to
be expected: the results of data reduction are
course prescribed by the raw data - themes can
only appear if those themes were included in the
questions asked and comments were prompted
on only a small number of aspects of care. For
the same reason, no taxonomy should be
regarded as definitive - it is always possible that
there may be further areas with a bearing on
satisfaction which have yet to be explored.
Similarly, local circumstances mean that in any
particular survey some of the issues raised may
not be relevant to patients' in other contexts.
The theme 'interdisciplinary framework', which
emerged through patients' comments, may be
such an issue; it seems unlikely that patients
would comment if the interdisciplinary team
were working smoothly as a unit. 'Hospital
access' appears another area which is only
commented upon when a problem arises. How-
ever, four components - treatment environment,
nursing care, physician care and patient informa-
tion were identified in both the quantitative
and qualitative data, suggesting that these may
tentatively be regarded as 'core' components.
It must be emphasized that the reliability and
validity data will help determine the degree of
credibility that will be, or should be, given to
research findings (Hinds et al 1990). As already
noted, it appears from published work that
instrument testing is rarely a priority for
satisfaction researchers, and is commonly en-
tirely overlooked. Satisfaction researchers have
relied too heavily on 'demonstrating' content
validity while ignoring other aspects of validity
and reliability. Well-documented and uncompli-
cated procedures for assessment of construct
validity and reliability are available and should
be applied as a matter of course. This study has
strengthened the conviction that it is desirable to
 Development and evaluation of a questionnaire to assess patient satisfaction
subject a satisfaction i n s t r u m e n t to a testing
process using s t a n d a r d p r o c e d u r e s and statistical
techniques. T h e results indicate that the W C S Q
has acceptable reliability and validity for assess-
m e n t o f satisfaction in patients receiving a m b u -
latory c h e m o t h e r a p y .
As the i n s t r u m e n t was designed specifically for
use with patients receiving s t a n d a r d o u t - p a t i e n t
regimes for c o m m o n cancers, the findings o f this
study c a n n o t be r e g a r d e d as directly applicable
to several c h e m o t h e r a p y p a t i e n t groups: in-
patients, paediatric patients, those v e r y ill and
those receiving intravesical o r intrathecal cyto-
toxic c h e m o t h e r a p y . W i t h s o m e m i n o r m o d i f i c a -
tions to w o r d i n g , it s h o u l d be suitable to apply in
a range o f nurse-led units p r o v i d i n g a m b u l a t o r y
o u t - p a t i e n t c h e m o t h e r a p y for c o m m o n cancers.
ACKNOWLEDGEMENTS
The authors would like to thank the patients who took
part in the study and the nursing staff of Education Day
Ward Nursing Development Unit at Worthing Hospital
for assistance with collection of data. This study was
undertaken by one of us (JS) as part fulfillment of the
requirements for the degree of MPhil at the University of
Southampton•
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 D e v e l o p m e n t and evaluation of a questionnaire t o assess patient satisfaction 137

APPENDIX

The WCSQ is reproduced in full in this appendix. A formatted version of the WCSQ is available from
the authors.

DAY W A R D W O R T H I N G HOSPITAL
'PATIENTS' EXPERIENCES OF C H E M O T H E R A P Y ' PROJECT

PATIENT SATISFACTION QUESTIONNAIRE

The Day Ward is keen to collect patients' views on the experience of chemotherapy treatment and the
way the treatment is provided on the Day Ward. The answers you provide to the following questions
will be treated strictly confidentially and will be processed by a researcher: your individual answers
will not be seen by nurses or doctors involved in your care. Most questions are answered by putting a
circle around the number beside the response you wish to make, as in the example below.
very happy I
fairly happy 2
neutral 3
fairly unhappy 4
very unhappy 5

At the end of the questionnaire is a space for any further comments or suggestion: any comment will
be most welcome. Thank you for taking time to help with this study.

Questions about yourself

• Your age
• Gender Female I
Male 2
• Usual employment
• Have you stopped working since diagnosis/starting Yes I
treatment? No 2
Does not apply 3
• Ethnic Origin
• At what age did you leave full-time education?
• How many times have you visited the Day Ward? 5 or less I
more than 5 but less than 20 2
20 or more 3

Questions about the day ward

How do you normally travel to the hospital? private car I
public transport 2
train 3
hospital transport 4
other (please state below) 5

Do you encounter any difficulties in getting to the no problem I

hospital? difficulty parking 2
public transport difficult 3
hospital transport difficult 4
other (please state below) 5

Considering things such as car parking facilities very accessible I

and service by public transport, would you say fairly accessible 2
Worthing Hospital is easily accessible for you? neutral 3
fairly inaccessible 4
very inaccessible 5
Do you feel anxious before arriving at the hospital very anxious I
for chemotherapy treatment? fairly anxious 2
neutral 3
fairly relaxed 4
very relaxed 5
After arriving on the ward on y o u r last visit, how less than 15 minutes I
long did you wait to be treated? 15to 30 minutes 2
more than 30 minutes 3
How happy were you with this length of wait? very happy I
fairly happy 2
neutral 3

EuropeanJournalof Ontology Nursing 3 (3),126-140

138 EuropeanJournalof OncologyNursing
fairly unhappy 4
very unhappy 5
In terms of appointment days very well I
and times, how well does the fairly well 2
Day Ward system for providing chemotherapy suit neutral 3
your needs? fairly poorly 4
very poorly 5
Are you happy with the level of privacy you have very happy I
when receiving chemotherapy? fairly happy 2
neutral 3
fairly unhappy 4
very unhappy 5
• Are you happy about being treated with other pa- very happy I
tients around? fairly happy 2
neutral 3
fairly unhappy 4
very unhappy 5
If a choice was available, would you prefer to be Ward I
treated in an open area (like the Day Ward) cubicle 2
or in a private cubicle? no preference 3

Do you feel anxious when very anxious I

receiving chemotherapy on the Day Ward? fairly anxious 2
neutral 3
fairly relaxed 4
very relaxed 5
• Is there any aspect of the Day Ward which you feel increases the anxiety associated with chemotherapy?:

Questions about your treatment

The following questions use a horizontal line to assess each of various aspects of nursing care on the Day Ward.Taking the
left end to be 'standard N H S level of care' and the right end to be 'the best care possibly imaginable'. Please place a
stroke through each line at the point at which you feel the Day Ward level to be. So, for example, if you feel for an aspect the
level on the Day Ward is a little above the normal NHS level so nursing care, you could mark the line like this:
I
standard NHS the best care
level of care possibly imaginable

standard NHS the best care

level of care possibly imaginable
• explanation of procedures F
and treatment
• concern for your privacy F
when talking about your
personal details
• concern for your privacy t
when giving treatment
• appreciation of your ~ t
individual needs
• nurses' technical skill in ~
giving chemotherapy
• medical knowledge of your ~ t
problem
• having time to talk to you ~ t
• reassuranceand support ~ t
• concern for your relatives/ ~ t
friends
• awareness of side-effects or ~
other problems you may be
experiencing
• help given in controlling or ~
reducing side-effects

Do you feel the Day Ward is below standard on any of these aspects? Please comment:
When diagnosed, how happy were you with very happy
the level of information you received about fairly happy
the disease and your condition? neutral
fairly unhappy
very unhappy

EuropeanJournalof OncologyNursing 3 (3), 126-H0

 Development and evaluation of a questionnaire t o assess patient satisfaction 139

What type of information was this, and from
whom? (please circle all which apply)
verbal, from a consultant
written., from a consultant
verbal, from Day Ward nurse
written, from Day Ward nurse
verbal, from GP
written, from GP
other (please state below)

Before starting chemotherapy, were you very happy

happy with the level of information you fairly happy
received regarding the treatment neutral
fairly unhappy
very unhappy
What type of information was this, and from verbal, from a consultant
whom? (please circle all which apply) written, from a consultant
verbal, from Day Ward nurse
verbal, from Day Ward nurse
What type of information was this and from Day Ward booklet
whom? (please circle all which apply) other (please state below)

How do you feel the giving of information could be improved?

Are you happy that you are given enough very happy
practical advice on what to do about side-effects fairly happy
when they occur? neutral
fairly unhappy
very unhappy
Are you happy that you are given enough very happy
advice on how to look after yourself between fairly happy
courses of chemotherapy, for example neutral
nutrition, skin care, oral care etc.? fairly unhappy
very unhappy
Do you feel the hospital support framework-nurse yes, a lot
counsellor, Day Ward staff, social yes, a little
worker, consultants, palliative care nurse-could neutral
be improved? no, not really
no, not at all
Please comment:
Overall, how happy are you with the very happy t
chemotherapy service provided by the fairly happy 2
hospital neutral 3
fairly unhappy 4
very unhappy 5
Please say whether you agree or disagree with the following statements:
• The nurses could be more approachable strongly agree 1
agree 2
no opinion 3
disagree 4
strongly disagree 5
The consultants could be more approachable strongly agree 1
agree 2
no opinion 3
disagree 4
strongly disagree 5
I wish staff had more time to answer my strongly agree I
questions agree 2
no opinion 3
disagree 4
strongly disagree 5

Questions for those finishing chemotherapy: please answer these questions only if you are within two months of
completing chemotherapy
• Have you received any information on what some information received I
will happen (regarding tests, monitoring of no information received 2
your condition etc) when you complete
chemotherapy?
Are you happy with the level of information very happy I
you have received? fairly happy 2
neutral 3

EuropeanJournalof OncologyNursing3 (3), 126-140

140 EuropeanJournalof OncologyNursing
fairly unhappy
very unhappy
After completing chemotherapy, which would GP
be your first point of contact should you have consultant
any worries or questions regarding your Day Ward nurse
condition? district nurse
(please select only one answer) patients' help line
the Friendship Group
other (please state below)

Comments

• pleaseuse this space for any further comments you have.

EuropeanJournalof Oncology Nursing 3 (3), 126-140