Introduction

However, health care delivery is challenged by a wide range of safety problems. The fact still remains that patients go through challenges on a daily basis worldwide in the course of receiving health care. This disturbing truth must be acknowledged and necessary actions taken to correct the problems that are contributing to unsafe health care.² These challenges include the development of the necessary conducive environment to ensure patient satisfaction. Patient satisfaction with health care healing environment depends on a patient’s overall evaluation of the health care experience.

Thus, to ensure patient satisfaction from the point of view of environmental health,

Thus, based on current economic environment and an increased focus on patient satisfaction, failure to provide a conducive health care healing environment to aid patient recovery makes even less sense than before. There is, therefore, the need to identify opportunities to improve efficiency, comfort, health, and safety of patients and the environment.^45-6 Thus, it is vital to determine patients’ assessment of health care healing environment of Ghanaian teaching hospitals and identify whether it impacts positively on patient satisfaction of core health care delivery.

Health Care Delivery in Ghana

The Ghanaian health care system is challenged with the difficult duty of improving and ensuring the health and well-being of all Ghanaian.⁷ The Ghana Health Service⁸ is mandated ‘to provide and prudently manage comprehensive and accessible quality health services in accordance with approved national policies’. Public health care services in Ghana are performed through a hierarchy of hospitals, health centres, maternity homes, clinics, and Community-Based Health Planning and Services (CHPS) strategy.⁹

Presently, Ghana has 4 teaching hospitals, with a fifth one set to be operational this year:

The United Nation’s Sustainable Development Goals (SDG 3) enjoin all nations to ensure healthy lives and promote well-being for all at all ages. To meet this objective, the Ghana Health Service has resolved to continuously improve the health and well-being of Ghanaians through the development of a better coordinated health system that places patients and communities at the centre of quality care (SDG 3). The whole vision is to create a health system that places the client at the centre of health care. As part of this integrated national strategy for improving the quality of care and patient safety, the Ghana Health Service hopes to continuously improve health outcomes through the development of a coordinated health care quality system that improves client experience by being responsive to the health needs and aspirations of the patients.¹⁰

Such goals can be achieved if care is taken to create a hospital environment that is conducive and safe to both the patients and the health care workers. It will permit health workers to constantly deliver safe and high-quality care to improve patient safety and so ensure patient satisfaction. However, most studies conclusively indicate that the health care service quality in Ghana does not measure up to the expectation of health care users.^7,8,11 According to Atinga et al,¹² patients in Ghana are so much concerned about health care environmental tidiness, cleanliness, and privacy during consultation with doctors and nurses. Thus, it is important to determine the mediating effect health care healing environment has on patients’ satisfaction of core health care delivery in Ghana.

Quality of Health Care Healing Environment

‘Humans interact with the environment constantly. These interactions affect quality of life, years of healthy life lived, and health disparities’.¹³ Consequently, the growing demand for safety, security, competence, and physical and psychological comfort of patients has brought about the need for a healing environment in health care facilities.^14,15 A healing environment is psychologically supportive for the welfare of patients to deal with the stress associated with illness.^3,16 As far back as the mid-19th century, Florence Nightingale saw the need to create a health care environment that aid patients’ recovery. According to Nightingale,^17,18 ‘patients would recover more quickly if they were cared for in an environment that had natural light, ventilation, cleanliness and basic sanitation’. According to World Health Organisation,² ‘good health and well-being require a clean and harmonious environment in which physical, physiological, social and aesthetic factors are all given their due importance. The environment should be regarded as a resource for improving living conditions and increasing well-being’. This is what the concept of environmental health also seeks to address. Environmental health entails the prevention or control of disease, injury, and disability associated with the interactions between people and their environment.³ Based on the environmental health concept, although it is important to create a healing environment for patient-centred care, a healing environment is much more than the aesthetics of a space. There is the need to understand and have a more integrated assessment of the physical dimensions that help in the physical, mental, and emotional well-being of health care facility users; whether they are patients, their family members, or health care workers.^5,6,14,19

‘The environment affects our health in a variety of ways. The interaction between human health and the environment has been extensively studied and environmental risks have been proven to significantly impact human health’.²⁰ For the purpose of this study, health care healing environment is discussed based on some of the dimensions of ‘A Staff and Patient Environment Calibration Toolkit (ASPECT)’ used to assess the quality of health care healing environment. These include privacy, compatibility, and dignity (patients’ privacy and dignity must be maintained while they are at health care facilities); views, nature, and outdoor (the degree to which patients can see out of and around the building); comfort and control (hospital layout should minimise unwanted noise in patient areas and patients should also be able to easily control the internal temperature and lighting); legibility of the place (building layouts should be clear and easy to understand, so patients can easily find their way with ease); and interior appearance (patients’ spaces should feel homely, the interior spaces should feel light and airy, and have a variety of colours, look clean, tidy, and cared for).^5,15,16,21 All these factors influence patients’ satisfaction with overall health care delivery.

Patient Satisfaction with Core Health Care Delivery

The need to achieve patients’ satisfaction and maintain patients’ loyalty has led to the need for health care providers to continually improve the quality of health care delivery (QHD) to make it more patient oriented.²² Thus, health care institutions need to understand the underlying forces that lead to patient satisfaction of the QHD.²³ Over the years, different researchers have evaluated patient satisfaction of core health care delivery service based on different service quality dimensions. Akter et al²⁴ based their research on platform quality, interaction quality, and outcome quality, that is, system reliability, system efficiency, system availability, system privacy, responsiveness, assurance, empathy, functional benefit, and emotional benefit. Chahal and Kumari²⁵ used physical environment quality, interaction quality, and outcome quality (ambient condition, social factor, tangibles, attitude and behaviour, expertise, process quality, waiting time, patient satisfaction, and loyalty). Atinga et al¹¹ assessed it based on communication, provider-patient relationship, environment, and waiting time. Abuosi and Atinga²⁶ evaluated it using tangibility, reliability, responsiveness, assurance, empathy. Sumaedi et al²⁷ used QHD, quality of health care personnel (QHP), adequacy of health care resources (AHR), quality of administrative process (QAP), perceived sacrifice, perceived value, and image. Finally, Rakhmawati et al²⁸ assessed it using the QHD, the QHP, the AHR, and the QAP.

For the purpose of this study, it was determined that most of these dimensions different researchers employed to assess patient satisfaction with core health care delivery in different countries can be appropriately grouped into 4 main categories proposed by Rakhmawati et al.²⁸ Therefore, taking the case in Ghana into consideration, the dimensions used for this study include the QHD, the QHP, the AHR, and the QAP. These were further broken down into their essential questions as shown in Table 1.

Table 1.

Health care core service dimensions for this research.

Hypothesis Development

Based on the literature review, the hypotheses were developed based on the transmittal approach. The transmittal approach requires only a single hypothesis stating that the mediator mediates the relationship between the independent and dependent construct.²⁹

Based on the research hypothesis established, the research framework was developed to test the hypothesis research as shown in Figure 1.

Figure 1.

Research framework.

Methodology

This is a cross-sectional study involving adult patient visiting a tertiary care setting. This study was conducted at the Physician outpatient department (OPD) and Polyclinic of Komfo Anokye Teaching Hospital, Tamale Teaching Hospital, and Cape Coast Teaching Hospital, all in Ghana from September to December 2017. The quality of health care healing environment was assessed using some of the established dimensions of ‘ASPECT’. The ASPECT is a tool for assessing the quality of the designed environment in health care buildings.¹⁵ It was chosen as it is a valid and reliable tool designed for evaluation of health care environment based on the database of more than 600 researches and have been applied and tested by different authors.^{6,1415-16,19,21} The dimensions used to evaluate the health care healing environment for this study include privacy, compatibility and dignity, views, nature and outdoor, comfort and control, legibility of the place, and interior appearance. Health care core service dimensions were used to assess the core health care delivery.

The ASPECT dimensions of ‘Facilities and Staff’ were omitted because based on the pilot study, the factor loading matrix of these 2 dimensions did not pass the 0.5 threshold and thus were found to be insignificant predictors of the mediating effect of health care healing environment on core health care delivery and patient satisfaction in Ghana. According to Field,³⁰ there is the need to ensure a fairly correlated data sample adequacy and assumptions testing in performing factor analysis. Thus, the correlation matrix used to examine the configuration of the relationship between the items to ensure variable significant values for the facilities and staff dimensions was less than 0.5.

Only the patients of these surveyed teaching hospitals were chosen to be the respondents of this study because they are the direct customers of the health care institutions who are directly impacted by the relationship between health care healing environment and core health care business. A pilot study involving 50 patients was initially conducted, and the results informed the final questionnaire of the study. To guard against sampling bias, the patients were grouped under clusters such as the records section, consultancy services, pharmacy, maternal and child health, laboratory, physiotherapy, and ENT. Convenience sampling was then be used to select the individual patients.

Convenient sampling method was used because patients were chosen based on their availability at a given time and their willingness to participate in this study. This is because researchers could not get a list of all patients who patronise the health care organisations, which the researcher would need to use as the basis of a probability sampling technique. Thus, irrespective of the perceived disadvantages of possible sampling error and data gathering bias, convenience sampling was deemed the best channel to select the target respondents of the study.

Questionnaires (see appendix 1) were administered to 660 patients, 18 years and above waiting to see their physicians at the 3 hospitals if they gave consent. Enrolment continued till the sample size was obtained. In all, 622 questionnaires were valid for the analysis. The data collected were edited, sorted, and coded using Microsoft Excel and Statistical Package for Social Scientists (SPSS). Structural equation model (SEM)–partial least square (PLS) analysis SmartPLS³² was the main tool used for the data analysis. SmartPLS is a SEM software created to test models. It affords the chance to draw the path model between variables and to define the indicators to the variables.³³

Respondents’ Profile

According to Table 2, Komfo Anokye Teaching Hospital had the highest number of respondents, that is, 34.1%; 33.4% are patients of Cape Coast Teaching Hospital and the remaining 32.5% are patients of Tamale Teaching Hospital, all in Ghana. About 51.1% of the study respondents were men; and most of them are between the ages of 21 and 50 years. In terms of educational level, a greater majority (27.7%) of the respondents are university degree holders. About 18.0% are polytechnic degree holders, 23.7% are secondary school certificate holders, while illiterates are about 9.8%. Most of the respondents have been patients of the particular teaching hospitals for 5 years or less as 65.1% fall within this category. Only 7.8% have been patients of the particular hospital for more than 20 years; 31.5% of the respondents are self-employed, while 24.8% are either civil or public servants. In addition, 18.8% are students and 8.8% are unemployed.

Table 2.

Respondents’ profile.

Data Analysis

First, the common method variance was examined because Podsakoff et al³⁴ opined that when data are gathered from the same person through self-reported questionnaires and both the predictor and criterion variables are obtained the same way, there is the need to assess the common method variance of the data. In addition to this, the same source bias or general method variance was also evaluated using Harman single factor test. Evidence of a common method bias occurs when primary constructs intercorrelations using the correlation matrix have correlations considerably larger (>0.90).³⁵ SPSS was used to check factor analysis and the results showed that there was no serious issue with method bias in this study. The intercorrelations also did not show any value above 0.9. Therefore, these tests demonstrate that there was no problem with method bias in the study. All the VIF values in Appendix 4, which shows how the variance of regression coefficient of one variable is influenced by the other predictor variables, were found to be lower than the threshold value of 10. Thus, there was no challenge of unstable indicator weights that can render the regression coefficient unreliable.^32,33,34 The results of the normality test as shown in appendix 5 indicate the skewness (how symmetrically distributed a data is, whether positive or negative) and kurtosis (how high a dataset is distributed around the mean) were all within the range of -2 to +2 as suggested by.^33,40 This shows that the data was normally distributed.

Partial least squares analysis using the SmartPLS 3.2.7 software³² was used to analyse the research model. Anderson and Gerbing³⁶ recommended a 2-stage analytical procedure for the measurement model (validity and reliability of the measures). Thus, these were confirmed. In addition, the structural model was also examined as Hair et al³³ recommend testing the hypothesised relationship of the structural model. This was assessed by bootstrapping method (5000 samples) to check the significance of the path coefficients and the loadings.³³

Measurement Model

Convergent validity and discriminant validity were used to assess the validity of the measurement model. The convergent validity of the measurement, according to Gholami et al,³⁷ is proven by examining the loadings, average variance extracted (AVE), and the composite reliability. The loadings were all higher than 0.7. In all cases, the composite reliabilities were all higher than 0.7 and the AVE was also higher than 0.5 (see Table 3).

Table 3.

Measurement model.

The Fornell and Larcker³⁸ criterion was used to assess the discriminant validity of the measures. That is, the extent to which items differentiate among constructs or measure distinct concepts. Its correlations between constructs and the square root of the AVE for that construct are compared and the rule of thumb is that all the diagonal values should be greater than the corresponding row and column values. According to Table 4, the study results achieved this, and this indicates that the measures were discriminant.

Table 4.

Discriminant validity: Fornell-Larcker criterion.

According to Henseler et al,³⁹ in addition to the Fornell-Larcker³⁸criterion, to very reliably detect the absence of discriminant validity, the heterotrait-monotrait ratio of correlations (HTMT), which is a multitrait-multimethod matrix, should also be assessed. Thus, this method was also used to test the discriminant validity. According to Kline,⁴⁰ to ensure discriminant validity, the HTMT value should not be greater than 0.85. Table 5 shows that all the values passed the HTMT 0.85. Thus, using both the Fornell and Larcker³⁸ criterion and the HTMT, the results show that discriminant validity was achieved.

Table 5.

Discriminant validity: Heterotriat-Monotrait ratio of correlations (HTMT).

Hypothesis Testing

Bootstrapping method using subsamples of 5000 cases was created to assess the model for each subsample.³³ This was used to generate results for all the path relationship in the model. All the path relationships were found to be significant at 95% confidence interval. According to appendix 2, (QHD → Healing Environment, ß = 0.194, P < .05; QHP → Healing Environment, ß = 0.201, P < .05; AHR → Healing Environment, ß = 0.197, P < .05; QAP → Healing Environment, ß = 0.235, P < .75, and Healing Environment → Patient Satisfaction, ß = 0.612, P < .05). The results of the structural model is as portrayed in appendix 3.

The fundamental consideration of mediation analysis is that there is a significant relationship between the independent variable and outcome through the mediator.⁴¹ This can be assessed by bootstrapping the sampling distribution of the indirect effect. A statistically significant indirect effect (t value > 1.96, 2-tailed, P < .05) should be taken as an evidence for mediation.⁴¹ Thus, the hypotheses were tested to confirm whether there is a mediation effect between the quality of core health care delivery (independent variable) and patients’ satisfaction (the outcome/dependent variable) through health care healing environment (the mediator). The entire 4 hypotheses were supported. This means that the mediator has a mediating effect between the independent and dependent constructs of the study. The result of the bootstrapping is presented in Table 6.

Table 6.

Hypothesis testing (mediating effect).

In addition to establishing the decisions for the hypotheses, the study also assessed the coefficient of determination (R²), the effect size (f²), and the cross-validated redundancy (Q²) of exogenous constructs on endogenous constructs. According to Table 7, the values for coefficient of determination (R²) of 0.375 and 0.373 indicate that the exogenous variables in this study explain 37.3% of variances in Health Care Healing Environment and 37.5% of variances in patient satisfaction. This demonstrates a sign of significant explanatory capacity.⁴²

Table 7.

Determination of coefficient (R²), effect size (f²), and predictive relevance (Q²).

Because the emphasis of PLS-SEM is on prediction, there is the need to determine the Q² using blindfolding procedure.⁴³ According to Hair et al,³³ if the Q² value is larger than 0, the model has predictive relevance for a certain endogenous construct and otherwise if the value is less than 0. According to Table 6, the Q² values were determined as 0.153 for Health Care Healing Environment and 0.175 for Patient satisfaction.

These figures arrived at were greater than 0 and therefore indicate that all exogenous variables have predictive relevance over the endogenous variable.^43,44 The f² values indicate the impact of each exogenous construct on endogenous constructs. The study shows that the effect of QAP on health care healing environment (f² = 0.065) is greater than that of AHR (f² = 0.040), QHP (f² = 0.043), and QHD (f² = 0.040). Obviously, this means that QAP has more effect on health care patients’ satisfaction in Ghana.

Discussion, Implication, and Limitation

From the point of view of environmental health, the environment within the hospital is very important if the well-being of health care users is to be supported. Hospitals are typical of multifaceted environments in which various facets including patients, staff, equipment, services, and information are interfaced. Thus, maintaining a safe environment shows the capability of the health care institution to ensure patient safety and well-being.⁴⁵ Thus, the findings of the study confirm that the health care healing environment compliment the core health care delivery to ensure patient satisfaction. The findings of the study add to the body of knowledge in health care facilities management literature.

The specific indirect effect of the bootstrapping shows that the different constructs that all contribute to core health care delivery (QHD, QHP, AHR, and the QAP) all contribute differently to patient satisfaction. The study results showed that QAP predicts patients’ satisfaction better, as its mediation effect is stronger than that of AHR, QHD, and QHP.

The study supports the fact that a healing environment is vital to patient-centred care. However, while improving the physical environment is important, a healing environment has much more facets than just the aesthetics of a space. In the building of a health care facility that respond positively to indoor air environment, there is the need to understand and have a more integrated assessment of the physical dimensions that help in the physical, mental, and emotional well-being of health care facility users; whether they are patients, their family members, or health care workers.^14,16,19

Although the paths of the hypothesis were supported, the results indicate that the effect sizes are small to medium. Therefore, it is important that health care providers highly increase the effect that the healing environment has on patient satisfaction of core health care delivery by drastically improving the quality of the dimensions of health care healing environment and the overall core health care delivery. In so doing, the health care environment will not only lead to patient satisfaction but also lead to enhanced performance, better worker satisfaction, and patient care.^19,46

The study findings also illustrate that once there is an improvement in the quality of the health care healing environment, it will have a positive significant effect on patient satisfaction of the core health care delivery, and in so doing, the mediating effect of the healing environment will increase to ensure patient satisfaction which leads to patients’ loyalty. Based on the findings of the study, it is recommended that, it is important the public hospitals improve their healing environment in addition to delivering quality health care service to ensure that patient satisfaction and loyalty are both sustained and enhanced.

The implication of this study is that if the hospital management team wants to further strengthen the mediating effect of health care healing environment in guaranteeing patients’ satisfaction of the core health care delivery, then they should create a healing environment that is psychologically supportive for the welfare of patients to deal with the stress associated with illness. These will guarantee the safety, security, and physical and psychological comfort of patients.^5,16,19

Like other studies, this study has its limitation; the study was conducted at the teaching hospitals where services and facilities are comparatively better than the district and regional hospital. It is therefore recommended that in future, the same study be conducted in some district and regional hospitals to determine whether the study results will be the same or different.

Second, the study employed a cross-sectional strategy which does not assess patients’ perception over a period of time. It is recommended that though difficult to achieve, a longitudinal study can be piloted to provide more insight.

Although the data were collected from only one country (Ghana), the ability to generalise the results may be a challenge. It is unclear whether the findings may have the same implications for the mediating influence of health care healing environment on patients’ satisfaction and core health care delivery in other context as patients’ perceptions maybe different in other countries.

Conclusions

The findings of the study can contribute to stakeholders of the Ghanaian health care sector’s quest to achieve the SDG 3. It is an irrefutable fact that stakeholders of health care delivery all over the world appreciate the importance of health care healing environment in contributing to patients’ satisfaction of core health care delivery. This study reinforces the fact that though dedicated health care staffs contribute to patients’ satisfaction of core health care delivery, the quality of the health care healing environment must ensure the safety and well-being of patients. This study is important in that it confirms that the patients’ overall assessment of satisfaction with the QHD can be influenced by the quality of the health care healing environment. It also goes to reinforce the assertion that a health care environment must be psychologically supportive for the welfare of patients.^16,19 It is based on this premise that stakeholders of Ghanaian health care delivery should undertake initiatives to continually improve the quality of health care healing environment as it is one of the key factors that contribute to the overall patient satisfaction with core health care delivery.

Although every health care institution seeks to provide a health care healing environment that will impact positively on patients’ overall health care experience, this has been met with challenges because the truth is that although health care healing environment varies from hospital to hospital, most hospitals try to create what they believe will lead to patient satisfaction without engaging the patients who are their customers to find out what they really need. Thus, with this study being based on patients’ perspective, it is believed that the results of this study will benefit 3 key stakeholders. These are the health care staff, the hospital management team, and the patients of health facility. The hospital management will be able to improve their health care healing environment as it has a positive significant influence on both patients’ overall health care experience and staff attitude to work.^5,6,14,19 The health care staff will benefit because there is proof that the quality of the health care healing environment also impact positively on the staff by decreasing stress and increasing effectiveness and improving their work performance and productivity.^5,6,14,19 Furthermore, the patients will also benefit because apart from the dedication of the health care personnel, the physical structures and hospital environment must also ensure the safety and well-being of patients.^5,6,19

In conclusion, this empirical validation offers more insight on the influence of health care healing environment on patients’ satisfaction of core health care business. To the best of the researcher’s knowledge, this study is one of first to use the ASPECT dimensions in examining health care healing environment in the Ghanaian health care sector. The study result has confirmed the strength of the ASPECT dimensions in predicting patients’ satisfaction. This study will contribute to knowledge in health care in general and that of a developing African country in particular.