Open access Research

Capturing the experience of the

hospital-stay journey from admission to
discharge using diaries completed by
patients in their own words: a
qualitative study
Craig S Webster, 1,2 Tanisha Jowsey,1 Lucy M Lu,3 Marcus A Henning,1
Antonia Verstappen,1 Andy Wearn,4 Papaarangi M Reid,5 Alan F Merry,2,6
Jennifer M Weller1,6

To cite: Webster CS, Abstract

Jowsey T, Lu LM, et al. Strengths and limitations of this study
Objective To capture and better understand patients’
Capturing the experience experience during their healthcare journey from hospital
of the hospital-stay journey ►► This study builds on previous work using health-
admission to discharge, and to identify patient suggestions
from admission to discharge care diaries, but appears to be the first to capture
using diaries completed by for improvement. the experience of the hospital-stay journey from the
patients in their own words: a Design Prospective, exploratory, qualitative study. patient’s perspective, by asking patients to complete
qualitative study. BMJ Open Patients were asked to complete an unstructured written an unstructured diary written in their own words.
2019;9:e027258. doi:10.1136/ diary expressed in their own words, recording negative ►► Our study recruited participants from a single vascu-
bmjopen-2018-027258 and positive experiences or anything else they considered lar surgical hospital ward—such participants being
►► Prepublication history for
noteworthy. purposively chosen to be those typically capable of
this paper is available online. Participants and setting Patients undergoing vascular completing a diary themselves for most of their hos-
To view these files, please visit surgery in a metropolitan hospital. pital stay.
the journal online (http://​dx.​doi.​ Primary outcome measures Complete diary transcripts ►► We collected diaries from the same patient popula-
org/​10.​1136/​bmjopen-​2018-​ underwent a general inductive thematic analysis, and tion during two time periods, 21 months apart, thus
027258). opportunities to improve the experience of care were allowing us to assess the representativeness of our
identified and collated. findings over time.
Received 14 October 2018
Revised 29 January 2019
Results We recruited 113 patients in order to collect ►► Our study is consistent with the modern concept
Accepted 13 February 2019 80 completed diaries from 78 participants (a participant of Safety-II, in that it aimed to identify positive and
response rate of 69%), recording patients’ experiences negative patient experiences, thus offering opportu-
of their hospital-stay journey. Participating patients were nities to make good performance better, in addition
a median (range) age of 69 (21–99) years and diaries to the elimination of the small number of remaining
contained a median (range) of 197 (26–1672) words each. poor experiences.
Study participants with a tertiary education wrote more in
their diaries than those without—a median (range) of 353.5
(48–1672) vs 163 (26–1599) words, respectively (Mann- Introduction
Whitney U test, p=0.001). Three primary and eight secondary The quality and safety of aspects of healthcare
themes emerged from analysis of diary transcripts—primary remains of significant concern throughout
themes being: (1) communication as central to care; (2) the world, yet statistics alone on adverse events
importance of feeling cared for and (3) environmental factors often fail to motivate the kinds of organi-
shaping experiences. In the great majority, participants sational change needed to bring about a
© Author(s) (or their reported positive experiences on the hospital ward. However, threshold shift to a better quality of care.1–4 In
employer(s)) 2019. Re-use a set of 12 patient suggestions for improvement were 2000, the WHO’s World Health Report recom-
permitted under CC BY-NC. No identified, the majority of which could be addressed with
mended greater engagement with the patient
commercial re-use. See rights little cost but result in substantial improvements in patient
and permissions. Published by experience in order to inform and improve
experience. Half of the 12 suggestions for improvement fell
BMJ.
into primary theme 1, concerning opportunities to improve
the quality and safety of patient care.5 These
For numbered affiliations see communication between healthcare providers and patients. recommendations have added momentum to
end of article.
Conclusions Unstructured diaries completed in a the development of the patient-centred, and
patient’s own words appear to be an effective and simple more recently, the person-centred healthcare
Correspondence to
Associate Professor Craig approach to capture the hospital-stay experience from the paradigms.4 6–11 While scope for improve-
S Webster; patient’s own perspective, and to identify opportunities for ment certainly still exists in healthcare, for
​c.​webster@​auckland.​ac.​nz improvement. the vast majority of patients, care proceeds

Webster CS, et al. BMJ Open 2019;9:e027258. doi:10.1136/bmjopen-2018-027258 1

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very well and research on patient safety has seen a real population was selected purposively as one where study
neglect of the opportunities for learning provided by participants would typically be capable of continuing
these positive outcomes and experiences.12 13 Learning their diaries shortly after their surgery. Patients scheduled
from what went right, in addition to what went wrong, is for transfer to another hospital or service were excluded.
consistent with the modern concept of ‘Safety-II’, which Each included patient was approached in their ward
focuses on making good performance better, in addition room by a researcher shortly after they had been admitted
to attempting to eliminate the relatively small number of to hospital. The study was explained to them, and they
remaining adverse events that continue to occur.14 gave written informed consent if they chose to partici-
We also know that the patient’s impressions of aspects pate. It was made clear to patients that involvement in
of their care, particularly around the quality of commu- the study did not take the place of complaints processes,
nication, may be different to that of their care providers, which remained available to them during their hospital
regardless of the actual outcomes of the healthcare stay. Patients were provided with an information sheet
received by patients.8 15 Furthermore, despite the fact that summarising the aims of the study, which contained the
patients in hospital spend the majority of their time on contact information of study investigators, independent
the ward, relatively little research that links patient expe- patient advocates and the institutional ethics committee
rience with quality and safety has been conducted in this in the event that patients had any concerns about the
care environment.16 17 study during their involvement.
Although diaries have been used in healthcare for
some time, these have been used almost exclusively to Data collection and diary completion instructions
collect information from a clinician’s perspective (ie, Data collection was planned to occur at two distinct time
for diagnostic, medication compliance and treatment-re- points in order to determine whether the results of our
lated purposes).18–20 Furthermore, healthcare diaries are study were stable over time, and was conducted by two
often completed by health carers about patients, rather research assistants (LML in period 1 and AV in period 2).
than by patients themselves.18 21 22 We were unable to find Given some uncertainty around using diaries to capture
any previous work using diaries completed by patients the patient experience in the way we intended, we aimed
themselves to record the hospital-stay experience from a to gather approximately double the number of diaries in
patient’s own perspective. Our aim in the current study each collection period as would typically be required to
was therefore to capture and better understand patients’ obtain thematic saturation with the use of interviews—
experience during their healthcare journey from hospital namely 40 diaries in each of the two time periods.23–25
admission to discharge, as expressed in their own words After each patient had given informed consent to partic-
in a written diary, and to identify patient suggestions for ipate, self-reported demographics data were collected by
improvement. the research assistant, including whether the participant
had received a tertiary education, and a measurement of
the emotional state of the participant using a self-reported
Methods 100 mm visual analogue scale with anchors of a sad face
The concept and aims of the study were presented to (0 mm) to happy face (100 mm).26 These demographics
clinical staff before the study began in order to antici- data were collected in order to describe the participant
pate potential problems in conducting the research, to population and to determine whether emotional state
introduce study personnel and invite nursing staff assis- or education level affected the ability of participants to
tance in terms of the collection of completed diaries from complete dairies. Participants were provided with a pen
patients. and an A6 paper diary in which to record their hospi-
tal-stay experiences, and informed that they were free to
Patient and public involvement complete their diary in their preferred written language.
We used an exploratory mode of data collection in our Participants were asked to record aspects of their hospi-
study in order to better understand patient priorities by tal-stay experience that they perceived as positive or
directly capturing the experiences and preferences of negative, in addition to anything else they considered
patients in their own words. Patients were not involved noteworthy, and to record the date and time at which
in the recruitment of participants to our study. However, each entry was made. On leaving the ward, participants
as part of the informed consent process, participating were asked to deposit their completed diaries in a drop
patients were asked whether they would like to receive a box, or to hand the diary to a study researcher or ward
summary of the findings of the study, and this was supplied nurse—thus completing study participation.
in plain language at the study’s completion. Presentations
of the findings were also made to hospital ward staff in Data analysis
order that our results could benefit future patients. All completed diaries were transcribed verbatim, de-iden-
tified and transcripts loaded into QSR NVivo V.10 (QSR
Participant recruitment International, Melbourne, Australia). Qualitative anal-
All patients scheduled to undergo surgery in a vascular ysis proceeded in two distinct stages. In the first stage, a
surgical ward were invited to participate. This patient general inductive approach was used to code sections of

2 Webster CS, et al. BMJ Open 2019;9:e027258. doi:10.1136/bmjopen-2018-027258

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text of interest, consistent with the sensitising concepts collection ran from 18 September 2013 to 12 November
of positive and negative experiences.27 28 Codes were 2014, during which data were collected part-time, 1 day a
then grouped into themes in an iterative process, and week, resulting in the collection of 38 completed diaries.
checked for consistency and accuracy by senior research Demographic and other data characteristics appeared
team members (CSW and TJ). In a further checking indistinguishable between the two data collection periods,
step, thematic coding was confirmed by an indepen- including self-reported patient ethnicity and emotional
dent professional agency external to the research team state, the number of words recorded in diaries and the
(Academic Consulting, Auckland, New Zealand). Statis- number of participants with tertiary education (table 1).
tical testing was not performed on qualitative findings and The distribution of the codes from which qualitative
supporting exemplar quotations are reported with pseud- themes were built were also very similar between the two
onyms. In the second stage of the qualitative analysis, time periods (table 1).
diary transcripts were re-read in their entirety in order to On average, participants in our study were in a rela-
identify specific instances of suggestions for improvement tively happy emotional state, with a median (range) visual
of the care experience made by patients, and details from analogue score of 74 (0–100), showing the majority of
these suggestions were collated. Our qualitative results scores at the ‘happy face’ end of the scale. There was
have been reported in accordance with the Consolidated no significant correlation between emotional state and
criteria for Reporting Qualitative research.29 Quantitative number of words recorded in patients’ diaries (Spear-
data were not normally distributed (Shapiro-Wilk test, man’s rho=−0.145, n.s.). There was also no significant
p<0.01), and so all comparisons were conducted with difference seen in the number of words recorded in
non-parametric tests using SPSS V.25 (IBM SPSS Statis- patients’ diaries according to gender—median (range)
tics, Armonk, New York, USA). words for male and female study participants being 184
(28–1672) words vs 209 (26–1201), respectively (Mann-
Whitney U test, p=0.99, n.s.). However, study participants
Results
with a tertiary education wrote significantly more in their
In total, 171 patients were approached and invited to
patient diaries than did those without a tertiary educa-
participate in the study, of which 113 elected to partici-
tion—median (range) of 353.5 (48–1672) words vs 163
pate and gave written informed consent (a 66% response
(26–1599), respectively (Mann-Whitney U test, p=0.001).
rate). In patients who gave a reason for declining to
The great majority of patients reported a very positive
participate 13 were going home within the next day and
thought that participation was not worthwhile, five felt experience on the hospital ward, for which they were
unwell and three had trouble writing. In the 113 study grateful:
participants, 78 returned a total of 80 completed diaries To be honest overall I am staggered at the high qual-
(a return rate of 69%, given that two patients returned ity of care offered at a public hospital and I am very
two diaries each). All returned diaries were completed in grateful, [the team] were amazing (David, 44 years).
English. The first period of data collection ran from the 4
November 2011 to the 21 December 2011, in which data Three primary and eight secondary themes emerged
were collected full-time, 6 days a week—resulting in 42 from the inductive qualitative analysis and are reported
completed diaries (table 1). The second period of data with exemplar quotations in table 2.

Table 1 Demographics and time periods

Period 1 Period 2 Total
Gender, male:female, n 48:22 26:17 74:39
Age, years, median (range) 68.5 (21–99)* 68.5 (25–86) 69 (21–99)
Ethnicity, n
European 53 33 86
Maori 6 5 11
Polynesian 5 2 7
Other 6 3 9
Emotional state, median (range) 74 (0–100) 75 (17–100) 74 (0–100)
Diaries returned, n 42 38 80
Total diary words, median (range) 197 (26–1599) 219 (31–1672) 197 (26–1672)
Participants with tertiary education, n 14 12 26
Codes, median (range) 11 (2–84) 12 (1–79) 11.5 (1–84)
*One patient aged 99 years elected to participate by dictating diary entries to her son.

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Table 2 Primary and secondary themes to emerge from qualitative analysis with exemplar quotations
Primary theme Secondary theme
1. Communication a. Explanations of what to expect
as central to care A full explanation [was] provided to wife and self in layman’s terms (Bob, 62 years).
Had surgical team around—all going well—good explanation regarding plans for the future (Vaughan,
78 years).
When I woke up 2-1-2014 I was mortified to find my right leg had been cut from groin to halfway down my
leg. Nothing of this magnitude had been communicated to me. Talk was of groin blockage (Molly, 72 years).
The team arrived, stared and looked generally uninterested. Doctor asked usual questions and responded
to mine, but all had vanished before I could ask the next question. It’s all superficial and pointless (William,
67 years).
MRI went well, when we eventually got there at 8 pm. My apprehension was possibly because of lack of
explanation. If I ever need one again it will be no big deal. Maybe a more detailed explanation would help
people relax before the procedure (Cooper, 78 years).
…I can go home… Thrombosis educator spent ages with me and was excellent—clear, patient and caring.
I feel very confident about my ongoing treatment (Mary, 37 years).
b. Patient feeling included and heard
I had a meeting with [the] anaesthetist which was very helpful and he really listened to me. He explained
thoroughly the procedure, etc, and I felt much more comfortable about having anaesthetic, as was a bit
nervous about it seeing [that] I have emphysema (Lillian, 75 years).
Reflected on past 2 weeks. Many discussions with doctors over past 10 days. All friendly, informative and
courteous. The type of questions I asked the doctors were all health related. What’s wrong? What effect
does it have? How do we fix it? How long will it take? At all times every question I asked was adequately
answered with positive explanations of what was happening (Sebastian, 63 years).
c. Patient position and power
I like the way two doctors talk beside you so that you feel included in the conversation (Sabine, 81 years).
Sometimes when lots of docs are in my room they just talk to each other and not always to me (Hemi,
67 years).
I refer here to the team of surgeons/doctors/nurses who do daily patient visits. While I think they are trying
to be inclusive, often there is dialogue between team members with the substance not necessarily being
passed on to the patient. Even after the frequency of my hospital stays I find it quite difficult on occasions
to pose questions or matters of concern. Partly I think this is because of the subordinate position of the
patient (lying down while team are all standing) (Felix, 69 years).
You are lying flat on your back in an unfamiliar bed environment when a ‘team’ of clearly very important
and distinguished people descends to STARE at you. Occasionally, you are asked a question by a group
member without identifying him or herself in any way. Usually no labels, identification, etc. While you
answer as best as you can you are left mystified about who you are responding to and the relevance of
your answer. While acknowledging the obvious skill experience professional competence you wish to help
both yourself and the whole organisation but you still don’t know who the bloody person is that you are
talking to!!! (Ian, 73 years).
2. Importance of a. Pain management
feeling cared for I had been to sleep late last night as my legs were painful. They were painful again this morning as the
magnesium salt dressings were biting away at my legs (Hannah, 81 years).
[I] had a restless night. My legs were very painful had to get out of bed and go for a walk to the TV room
(day 1)… I had a good night no pain whatever they gave me worked very well (Ngiare, 70 years, day 2).
Sometimes there is too much rush because doctors are coming to see you. Nurses start working at 10
times [their usual] speed. In [the] process they cause too much pain especially with bandages being pulled
out (Jim, 56 years).
They send me back for angio and they can’t put me to sleep. It’s a big risk because of my heart and that I
can’t lie on my back because of the pain on my crack rib. So the guy has to stay close to give some more
higher bigger pain killer to help me with my pain while the doctor was doing to angio (Talia, 61 years).
b. Characteristics of HCP staff
Also senior dermatologist who is treating a rash on my face showed me that the cause was not as bad as
I had originally thought and the cure was quite achievable. He was very approachable and kind (Sabine,
81 years).
The nursing staff in the ward in the main were excellent—efficient, caring, gentle, knowledgeable, kind
and all smiles. However, unfortunately there were one or two other nurses whose lack of compassion and
abruptness of manner made me wonder why they were nurses at all—perhaps to them it is just a job!!!
(Hank, 79 years).
Nursing staff all caring and very helpful and willing to provide the smallest request (Grace, 78 years).
Continued

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Table 2 Continued
Primary theme Secondary theme
3. Environmental a. Catering: ‘Sheraton quality’ or ‘cooked terribly’
factors Cannot fault service, food of Sheraton quality (day 1)… I cannot believe the rubbish they serve you. I have
shaping patient been finding in my menu for several weeks now the same (white bread in a hospital?) (day 10) … Evening
experiences meal excellent. Young new girl must be in a hurry to knock off. Served meal and back for tray 20 min later. If
not finished it gets left for the night (untidy) (Simon, 69 years, day 13).
The food here has a lot to be desired. Good ingredients but cooked terribly (Stephen, 64 years).
b. People: strangers, visitors and loved ones
This isn’t the hospital’s fault but I always end up in a room full of snorers. It drives me bloody crazy
(Stephen, 40 years).
I find the [hospital] 5 star and nursing staff 5 star as well. Food only 1 star but glad to get when hungry. Bad
side. Nurses bell loud when trying to sleep plus toilet door very loud to close at night. It would be helpful if
the nurses turned only the small light on in the middle of the night. If the ward doors were closed at night it
would cut the noise down of the nurses’ buzzer going off (Ben, 67 years).
[It] can be pretty boring in ward. I wish my family could be in here more so it wasn’t so boring (Hemi,
67 years).
It’s very hard at night when you feel so alone (Bess, 59 years).
…Later in the evening 7.00ish there was a lot of wee children running around and screaming shrilly!! We
understand that kids can visit their family but is it necessary to make so much noise? And their behaviour
not controlled (Markel, 78 years).
As usual, [name removed], my wife, visited me and also four other relatives. Five lovely ladies cheering me
up. Visitors are so essential for the well-being and recovery of patients (Vincent, 80 years).
c. Technology shaping experience
Communication: This is the area which needs a lot of improvement. There is no landline in the whole ward
and you have to call the nurse to get you a cordless phone to make a call. The cordless phone was broken
and the quality of the sound was bad. It would have been great if the hospital could provide some internet
access either through Wi-Fi hot spots or some plug in the ‘whanau (family) room’. [I] feel cut-off from the
rest of the world when there is no internet access. Whanau Room: This room is way too small. It is probably
the smallest ‘whanau room’ I have ever seen in all hospitals in NZ. It can accommodate a maximum of 4
people (Charles, 48 years).
To tell you the truth the one thing I despise about hospitals is the lack of anything to do. It looks like the
rooms were supposed to be equipped with televisions but someone forgot to install them (Stephen,
40 years).

Communication as central to care substantially reduce their anxiety about unfamiliar

In many cases, the main driving factor behind whether upcoming procedures (table 2, section 1a).
participants deemed their experiences as positive or Communication was considered particularly important
negative centred around communication and interac- on discharge in order that patients would know what to
tions with healthcare providers (HCPs), how information expect during their recovery and in order to allow them
was conveyed (or not) to the patient and how acces- to continue with any needed medications (table 2, section
sible HCPs made themselves to the patient and/or the 1a—Mary).
patient’s family. Positive comments greatly outnumbered
negative ones. However, participants often reported not Patient feeling included and heard
being told that their medications or care plan had been Participants identified that their feeling of inclusion in
changed, or that they had finished their current medi- decision-making and of being ‘heard’ by HCPs substan-
cation prescription. Participants also reported specific tially determined their overall experience, with real
circumstances where communication was poor between potential to reduce patient anxiety if done well (table 2,
HCPs and patients, for example, in patients with hearing section 1b).
or sight impairment.
Patient position and power
Explanations of what to expect Patients reported that at times HCPs would discuss their
Many patients were pleased with the explanations given case with other HCPs in front of them (but without
to them and their family about upcoming procedures. directly including them in the conversation). Patients
However, some reported that they were provided with interpreted this in one of two ways, they either saw it as
limited information, given poor explanations of their inclusive by way of HCPs having a conversation within
health status and of upcoming procedures or felt that hearing distance, or they interpreted it as excluding them
they were not listened to. Patients suggested that having from conversation (with the implication that this was
more details explained to them ahead of time would impolite). These different perspectives of similar events

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illustrate the subjective nature of healthcare encounters, hospitals they had been in. Other patients were more crit-
and the importance of confirming with patients that they ical of the catering quality (table 2, section 3a).
feel included in—and are satisfied with—an encounter.
Two patients suggested that their feeling of inclusion People: strangers, visitors and loved ones
and power to pose their questions to HCPs was partially Patients in this study were in a hospital ward where they
determined by people’s positions and locations in the shared a room with other patients whom they did not
room, in the sense that patients may feel subordinate know. They were allowed visitors (family and friends)
because they are lying down, while HCPs are standing during specific visiting hours and they had access to a
over them (tables 2 , section 1c—Felix and Ian). Hence, Whanau (family) Room on the ward. Sharing the space
despite the efforts of HCPs to include patients in conver- with strangers was often reported as having negative
sations concerning their care, some patients felt that their implications, such as lack of privacy during consultations
power and agency were mitigated to some degree by their and noise when participants wanted quiet, for example,
‘subordinate position’ of lying in bed. when attempting to sleep.
The constraints of the environment—lack of Wi-Fi
Importance of feeling cared for access or television, or other comforts of home including
Participants appreciated it when HCPs demonstrated loved ones—often left participants feeling bored and
that they cared for them during their communications lonely. However, some participants suggested that having
and through their actions—this commonly involved other patients in their ward room could also be positive
HCPs attending to some aspect of the patient’s personal in terms of having someone to chat with and pass the
comfort during the interaction. time with (table 2, section 3b). Similarly, a number wrote
about visitors to the ward; either to visit themselves (which
Pain management were usually linked with positive associations), or other
Episodes of pain related to their condition were often patients (which were sometimes viewed more negatively).
described by patients in their diaries. Participants
described the types of pain, levels of pain, their own Technology shaping experience
efforts to manage pain and the efforts of HCPs to manage Participants described the impact of the environment on
it. The management of pain was central to patient’s feel- their experiences in terms of their access to technology
ings of being cared for (table 2, section 2a). (telephones, Wi-Fi and television). The value of access to
technology was framed in terms of patients feeling both a
Characteristics of HCP staff
sense of social connection and of entertainment.
In describing characteristics of HCPs that made patients
feel cared for, patients often used terms such as ‘approach- Patient recommendations for improved service delivery and
able’, ‘kind’, ‘smiles’, ‘gentle’ and ‘helpful’. Although few patient experience
diaries contained negative feedback on the conduct or From the second stage of the qualitative analysis, 12
attitude of different hospital staff, such accounts, when problem areas with the hospital experience were identi-
they did occur, left participants feeling uncared for fied. These are shown in table 3 along with the poten-
(table 2, section 2b—Hank). tial solutions proposed by patients, and ordered by
the primary theme category for each. Suggestions for
Environmental factors shaping patient experiences
improvement were most commonly associated with
Aspects of the hospital environment featured in just over
primary theme number 1—communication as central
half of patient diaries, indicating that participants viewed
to care (6 of 12 suggestions), followed by primary theme
it as influential in shaping their experiences. For the many
number 3—environmental factors shaping patient expe-
who provided positive feedback concerning the hospital
rience (5 of 12 suggestions).
environment, aspects that they highlighted included
levels of cleanliness, the quiet atmosphere within the ward
and the friendliness of staff. While many comments high-
lighted specific aspects of the environment as having a Discussion
negative or positive influence on their experience, other Eighty completed diaries recording the negative and
comments pointed to broader issues of how the hospital positive experiences of patients during their hospital
environment limited their movement, robbed them of stay were collected, each containing a median (range)
the capacity to ‘do’ anything with their time, reduced of 197 (26–1672) words. Experiences reported in diaries
their sense of social connection and disrupted their sense were in the great majority positive. Three primary
of autonomy, privacy or comfort. themes emerged from diaries, these being: (1) commu-
nication as central to care; (2) importance of feeling
Catering: ‘Sheraton quality’ or ‘cooked terribly’ cared for and (3) environmental factors shaping expe-
The quality of food was a relatively common topic that riences. Twelve problem areas were also identified by a
patients reported on, but a range of views were evident. minority of patients with proposed solutions—6 of 12 of
Some patients reported that the catering quality was of an these problem areas involved aspects of communication
adequate, or even high standard, compared with other between HCPs and patients.

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Table 3 Problem areas identified from diaries with proposed solutions

Problem identified by Corresponding primary Specific improvements
patients theme Details proposed by patients
1. Communication around 1 (Communication as Patient did not understand the Scheduling office needs to
procedure planning central to care) procedure the scheduling office have a better understanding of
wanted to bring them in for, and so technical language so they can
refused it—better explained later by explain procedures better on
surgeon the phone
2. Delays and scheduling 1 Waiting for hours in a strange area Better communication with
difficulties of the hospital for a scan, or worse, patients on what is happening
for surgery when nil by mouth, can with their care
be distressing
3. Communication with 1 Ward phone does not allow toll calls Remove toll bar
outside world to be made outside of the Auckland
region
4. Communicating with a 1 During ward rounds or other times, A one-on-one consultation
crowd of doctors it is hard to know who is who, and with patient at key points
to ask questions when there are during care would make
many doctors at once by bedside communication easier for
patient
5. Changes in medications 1 Patients not told that their Make informing the patient
or care plans not medications or care plan had part of the process for making
communicated to patient been changed, or that they had changes in care plans or
finished their current medication prescriptions
prescription
6. Problems with discharge 1 It can take many hours for Paperwork could be prepared
of patients from ward paperwork to be signed off even in advance to save time.
though the patient is ready to go Assess all patients for pain
home. Pain management of patient before discharge and give
at discharge is also important appropriate prescriptions
7. Caring for patients with 2 (Importance of feeling Blind or deaf patients were Better awareness in staff of
specific disabilities cared for) sometimes treated in a way that patient’s disabilities
made it clear that staff did not know
of the patient’s disability
8. Meals sometimes too 3 (Environmental Patient was not able to finish any of A small-meal option would be
large factors shaping patient her meals useful
experiences)
9. Difficulties for out-of-town 3 Accommodation and parking are Proactive, targeted assistance
patients expensive. Some assistance is for out-of-town patients
available to out-of-town patients
for these costs but no one tells you
about it
10. Mixed-gender ward 3 Can be uncomfortable or Keep male and female ward
rooms were disliked embarrassing to have one young rooms separate or at least ask
female in same ward room as three before bringing in a new patient
older men
11. Difficulties sleeping at 3 Loud noises in ward and bright Close doors at night to reduce
night lights keep patients awake noise, dim lights
12. Boredom in ward 3 Nothing to do for many hours, Have newspapers for sale, Wi-
particularly in private rooms Fi for patients, more cordless
phone access, TV

A limitation of this study is that it was conducted in a data collection. Furthermore, our findings appear to be
single vascular surgical ward. However, the stability of the congruent with other large-scale quantitative studies on
data characteristics and findings across the two study time the patient experience (discussed below). We purpo-
periods, 21 months apart, suggests that our results are sively chose a population of patients for our study who
representative of the patient population from which they were able to complete a diary themselves for most of their
are drawn—and this is despite full-time versus part-time hospital stay. However, composite diaries could be kept

Webster CS, et al. BMJ Open 2019;9:e027258. doi:10.1136/bmjopen-2018-027258 7

Open access

in other patient populations where care providers or Although variable amounts of text were recorded in
family members make entries during the periods of care diaries in our study, the overall participant response rate
where the patient is not able to make diary entries them- of 69% was considerably higher than other paper-based
selves (as is often done with patients in the intensive care patient diary studies where diaries were used for diag-
unit).22 The completion of diaries by patients appears to nostic or treatment-related purposes.36 37 Reasons for the
be a simple and intuitive method of capturing the patient relatively high participant response rate in the current
experience which patients appear to engage with, and so study are likely related to the nature of the data recorded
this approach could easily be extended to other health- in diaries and the way in which we asked patients to use
care domains.12 30 The use of questionnaires to assess their diaries. In previous healthcare diary studies patients
patient satisfaction with healthcare clearly has its place, are typically expected to make entries at regular, desig-
and questionnaire data are generally considered to be nated time periods and about specific events or physio-
simpler and faster to summarise than the qualitative data logical variables, that is, to make diary entries determined
yielded by unstructured diaries. However, rapid methods by the clinician’s perspective. In these circumstances,
of analysis of qualitative data are available.31 In addition, patient compliance with the use of a paper diary is gener-
questionnaires come with their own frame of reference, ally poor.37–39 Our study, by contrast, had a very different
since the questions are predetermined, and do not lend aim—we wished to capture the hospital-stay experience
themselves to the capture of individual narratives. Ques- from the patient’s perspective and in their own words. We
tionnaires can be used only after it is known which ques- did not require entries to be made at specific times, but
tions are meaningful or important to ask. In fact, among asked patients to record anything which was important
its other uses, an unstructured diary approach can guide to them whenever they wished (thus minimising retro-
question and questionnaire selection in subsequent work. spective recall bias, a common limitation with question-
Ultimately, the most appropriate data collection method naires). The events recorded in diaries often formed
will be determined by the aims of any particular study, as personal narratives, hence making it more likely that
each approach has its own strengths and limitations.18 patients would complete diaries.7 40 Our findings suggest
In recent years, the value of patient experience and that the use of unstructured written diaries completed by
feedback as an important source of data on the quality patients can be a practical and useful measure of patient
and safety of healthcare provision has become more experience.
widely appreciated, including in a number of large-scale In our study, the two largest influencing factors of the
studies. In a systematic review of 55 published studies patient experience were the effectiveness of communica-
considering patient-centred care and outcomes, consis- tion with HCPs, and environmental factors in the hospital
tent positive associations were seen between measures ward—both being strongly reflected in patient suggestions
of patient experience, patient safety and the effective- for improvement, thus emphasising the scope for co-de-
ness of healthcare in a wide range of diseases, settings sign of aspects of care in hospital (table 3).41 For example,
and outcome measures.32 In a 13-country study of 61 168 poor communication about a patient’s care was associated
nurses and 131 318 patients, the reported quality of the with feelings of frustration, being uncared for and confu-
hospital environment was significantly associated with sion about what to expect next. However, this was not
patient satisfaction, and the quality and safety of patient the case when care changes were made, but where these
care. More specifically, in a study of 2249 patients using were effectively communicated to the patient. In partic-
the Picker Patient Experience Questionnaire, a validated ular, effective communication is important in preventing
survey instrument used internationally, almost 90% of medication adverse events when changes are made to a
respondents were found to be satisfied with their period patient’s medication—with one study of 2471 hospital
of inpatient care, and the results of a multiple linear inpatients indicating that medication adverse events are
regression indicated the major determinants of patient the most common type of safety incident reported by
satisfaction were physical comfort, emotional support and patients.13 Similarly, discharge procedures were identified
respect for patient preferences.33 It has also been known as an important opportunity for coordinated communica-
for some time that malpractice claims against HCPs are tion with the patient (table 3). Others have shown that revi-
more likely when patients believe communication about sions to the discharge procedures intended to make the
their care was poor, rushed or inadequate and when HCPs process more patient-centred and to highlight follow-up
devalue the patients’ views—thus further emphasising the requirements, can significantly improve patient experi-
importance of considerations of communication and the ence and satisfaction with discharge.42 43 In addition, a
patients’ perspective during healthcare.34 35 The above number of environmental factors highlighted by patients
findings are consistent with the qualitative findings of could be remedied with little cost and effort (table 3). For
the present study in the sense that the great majority of example, the importance of efforts to promote sleep at
patients returning a diary were satisfied with their care night by closing doors to reduce noise and dimming lights
and that the three emergent primary themes of our study is supported by research showing the substantial contribu-
address many of the same issues as those identified as tion of sleep to healing and patient well-being.44 45
the determinants of patient satisfaction, including the Our results also contained diary entries from two
leading importance of communication. patients who independently identified themselves as being

8 Webster CS, et al. BMJ Open 2019;9:e027258. doi:10.1136/bmjopen-2018-027258

 Open access

in inferior power relationships with their HCPs, through Provenance and peer review Not commissioned; externally peer reviewed.
their position of lying down in their hospital bed (table 2, Data sharing statement Consistent with our institution’s ethics approval, no
section 1c). This power relationship can be ameliorated additional data are available.
simply by the HCP sitting down before conversing with Open access This is an open access article distributed in accordance with the
the patient. In a study of 120 patients on a neurosurgery Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which
permits others to distribute, remix, adapt, build upon this work non-commercially,
ward, patients perceived consultations with their HCPs and license their derivative works on different terms, provided the original work is
to be more positive, informative and to last longer when properly cited, appropriate credit is given, any changes made indicated, and the use
HCPs sat down before a conversation, even when consul- is non-commercial. See: http://​creativecommons.​org/​licenses/​by-​nc/​4.​0/.
tations were of the same length of time.46

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10 Webster CS, et al. BMJ Open 2019;9:e027258. doi:10.1136/bmjopen-2018-027258