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Introduction
Wherever you are in the world, the COVID-19 pandemic has had a global impact on every human being. This pandemic has had major consequences on the majority of the population, increasing feelings of instability, distrust and tension in access to health care.
The widespread outbreak of the COVID-19 remains a challenge for public health and medical care worldwide.1 COVID-19 had a big impact on everyone’s life, but probably some people were affected more than others, namely patients with other medical conditions or chronic diseases.2 Management of the immunosuppressed, especially patients with cancer, has become particularly difficult in the pandemic setting, with a rupture of the system as it worked.3
Following severe social distancing and lockdown measures, hospital systems have increasingly transitioned to telemedicine for nonpandemic health care services.4 Access to health care, routine and screening exams, treatments and consultations were increasingly impaired, aggravating the disease trajectory for many patients.4 Since the beginning of the pandemic, multiple changes in the provision of cancer care from the point of diagnosis, including modification of treatment schedules (change in therapy, deferral, or omission), have been advised by professional bodies and commissioners of services globally.5-7 Many patients did not seek medical assistance whether because of lack of access to oncology providers,8 restriction of mobility and the safety procedures to be followed.9 Also, the fear of becoming infected with COVID-19 was one of the major reasons patients postpone consultations and exams.1-3,9,10
A growing body of literature has found higher frequency of mental health symptoms (e.g., anxiety, depression) among patients during the COVID-19 pandemic. For instance, Ng and colleagues reported that 66% of patients with cancer reported a high level of fear of COVID-19.11 Many measures were based on social restriction, potentiating a feeling of insecurity and unsafety in social interaction. Also, many patients felt that hospitals were an insecure place, with a high risk of COVID-19 infection. For many patients, especially oncologic ones, the doctor-patient relationship is essential; as the pandemic could directly interfere with this connection, and also with routine exams (essential to studying the development and progression of a disease), many individuals felt uncertainty, fear and anxiety.12 Also, for many people it is important to do screening exams, to achieve early diagnosis of their diseases. In this manner, many people faced a terrible ambivalence in going or not to hospitals, or to the exams, namely colonoscopies.9 Facing these emotional conflicts, with many questions and doubts, but also with no health professional available and open to respond to these emotional needs, many patients were left on their own. As reported, many patients experienced high levels of psychological distress.1,10
This study aimed to assess the level of satisfaction and the feeling of safety of patients who underwent endoscopic exams at a Gastroenterology unit during the second wave of the COVID-19 pandemic, as well as the impact of the measures taken to mitigate the influence of this circumstance on the experience of patients.
Methods
We started to construct a clinical interview aimed to address patients’ satisfaction with care, but also their feeling of safety and security.
In the clinical contact and interaction, some questions emerged spontaneously and provided relevant information about how patients were managing the pandemic. Since some of those questions, statements and preoccupations were recurrent, we built a closed interview, based on such topics, in order to address several difficulties and problems presented by patients in this specific context.
Our sample was collected from patients that attended our Gastroenterology department at CUF Cascais Hospital to perform elective endoscopic exams. As inclusion criteria we selected: people 18 years old or older, basic education or higher, without cognitive or brain impairment. Cognitive impairment is, among others, a person’s inability to think, learn, decide and/or use judgment.13
The Portuguese education system is divided into 5 levels: nursery: 3 months to 3 years of age, preschool: 3 to 6, basic education: 6 to 14, secondary education: 15 to 18 and higher education. Basic education is compulsory education in Portugal.
Patients with complete basic education were included in the sample. The level of education was one of the questions asked to all patients before including them in the sample and starting the questionnaire.
Immediately before the endoscopic examinations, we carried out a preliminary assessment based on the patient's ability to understand the information/instructions that were given to him. If the patient seemed capable of understanding, thinking and responding to basic questions and instructions, we consulted his clinical file and based on this information, and on the anamnesis carried out by the nursing team, we selected patients without apparent cognitive limitations.
All patients agreed with the informed consent and agreed to participate in the study.
The interview was developed to contain 10 questions: six containing safety regarding the exams; three concerning relationship/communication with the health professionals; and one question that addressed global satisfaction with care (See Attachment 1).
We chose to use closed questions, to facilitate the responses of the patients, and not to be a burden or potentiate confusion.
After constructing the interview, we applied it to a small sample of six patients, to appreciate how they dealt with the questions and if they understood them well.
Then we applied the interview, always by phone, the day after the exams took place.
All the interviews were made by the same nurse that collected all the data and had a duration of 10 to 15 minutes.
We asked the patients to classify the concordance or discordance with the quotes, in a Likert scale ranging from total discordance, partial discordance, indifferent, partial concordance, and total concordance.
After applying the interview, we divided the questions into three major dimensions:
Safety, that addressed questions about the safety of the environment, hygiene conditions and the comfort people felt in hospital (question 1, 2, 5, 7, 8 and 9);
Relationship and communication, that focused on questions concerning the relationship between health professional and patient, how communication and connection was affected (question 3, 4 and 6);
Satisfaction with care dimension (question number 10).
Results
Our sample was composed by 60 patients, with a mean age of 56.98 (± 13.19) years; and 55% were female (n= 33).
They went to our unit to undergo colonoscopy (30%), endoscopy (21.7%) or, in the majority of the cases, to perform both of the exams (48.3%).
As we can see on Table 1, most people felt secure and confidence in health professionals. Also, they felt that the hygiene was adequate and proper.
Table 1: Dimension safety of the interview.
| Scale (%) | Total Discordance | Partial Discordance | Indifferent | Partial Concordance | Total Concordance |
| Question 1 | - | 6.7 | 11.6 | 51.7 | 30 |
| Question 2 | - | 10 | 18.3 | 53.3 | 18.4 |
| Question 5 | - | 3.3 | 10 | 75 | 11.7 |
| Question 7 | - | 6.7 | 31.7 | 58.3 | 3.3 |
| Question 8 | 26.7 | 53.3 | 15 | 5 | - |
| Question 9 | 3.3 | 20 | 23.3 | 45 | 8.4 |
In Table 2, we present the results of the dimension relationship/communication. Although the majority of patients felt safe with the assistance of the health professionals, and felt it was a secure environment, some experienced difficulties in communication (and consequent discomfort) mainly because of the equipment used by doctors, nurses and other caregivers (masks, glasses, dressing outfit).
Table 2: Dimension relationship/communication.
| Scale (%) | Total Discordance | Partial Discordance | Indifferent | Partial Concordance | Total Concordance |
| Question 3 | 6.7 | 20 | 45 | 28.3 | - |
| Question 4 | 3.3 | 13.3 | 16.7 | 63.4 | 3.3 |
| Question 6 | 23.3 | 53.3 | 21.7 | - | 1.7 |
In what concerns the dimension of satisfaction (presented in Table 3), we can observe that most patients felt safe, secure and satisfied, and experienced that undergoing the exams as a good option.
Discussion
Our study showed that, despite all the constraints and negative impact related with the COVID-19 pandemic on access to health care, patients revealed an overall satisfaction with their global experience and care when undergoing elective endoscopic procedures. Most of the patients felt they made a good choice and were satisfied after going to the hospital.
Although the COVID-19 pandemic disrupted the healthcare system worldwide and access to medical care was limited, mainly performed by telemedicine, the patients needed to undergo exams to better understand and diagnose their medical conditions.9
Most patients faced an internal conflict of going to a hospital or staying safe at home. Our study highlights that most patients felt safe with health care professionals. Also, they felt the environment was safe, clean and calm. And this could have contributed to the overall satisfaction with care.
This is an important result, as many patients were facing an intense fear of being infected by COVID-19. This emotional reaction can “freeze”, impeding people to search for medical assistance and help. This happened especially in routine exams that can help physicians detect beforehand some medical conditions, as cancer and chronic diseases.10
Nevertheless, our study reveals that most patients experienced a sense of security and safeness whether with the physical environment, or with interaction with health professionals. During the pandemic, we applied several measures in order to adapt to demands of the current situation: the use of masks was mandatory for all patients and health professionals; the temperature of all patients was measured when entering the hospital; no attendants were allowed inside the hospital (with exception of children and elderly); all patients were asked to disinfect their hands when entering the hospital and also when entering our department; all patients underwent a PCR test 72 hours prior to the exams. Also, all medical offices and examination rooms were fully cleaned after each exam or consultation and all members of the health care team (administrative and auxiliary staff, nurses, doctors) had specific training regarding the new implemented measures.
Our study shows that most patients evaluated that the hygienic conditions were acceptable and suitable, and that these provided a safe environment. The implementation of all the above measures could have potentiated this result, providing a sense of an aseptic and controlled environment.
It is especially important to underline the relationship between health care professionals and patients, and how it creates a secure base.12 The pandemic setting interferes with this relationship, not only due to the patients’ fear of getting infected at the hospital but also the contrary: some health professionals fear getting infected by patients.14
Generally, a worse interaction with healthcare workers may negatively impact compliance and the inclination to ask for help, and it may decrease patients’ satisfaction with care.15
In our study we choose to evaluate the level of satisfaction after the exam was done, because we presumed that before the procedure most people felt intense emotions of fear, frustration and anxiety. The exams were essential to understand their medical condition; however, the risk of catching COVID-19 was considered to be high.3,16
One of the most important issues for clinical oncologists was cancer management.17 Commonly, the cancer population is vulnerable and worried about delays and interruptions of anticancer treatments.14 Most studies that focused on satisfaction with care during COVID-19 were aimed at studying the impact of telemedicine,18,19 data regarding patients’ satisfaction with care during exams and face-to-face is scarce. Despite telemedicine being an important instrument used in the pandemic, it imitates the action of health professionals18,19 and as so has several limitations.
The relationship with health professionals can potentiate a feeling of security and connection,12 especially important when one faces serious medical conditions or life threating disease. With the pandemic, everyone felt intense emotional reactions, especially fear, and all the equipment necessary to prevent infection for COVID-19 affected and interfered with the relationship dynamics. If on one hand the use of masks brought an overall sense of protection and safety, on the other hand it affected communication, whether non-verbal or verbal content, as people may experience difficulty in understanding what others are saying.14 One of our results suggested, as expected, that the use of masks and other safety material, affected the communication with health professionals. The use of masks affected the verbal communication, as sometimes it is difficult to understand what people are expressing but it also affected the nonverbal dimension in communication that is absolutely essential to a healthy relationship.
Some studies underlined that the levels of satisfaction may influence compliance and continuity of treatments, affecting the overall quality of clinical care.20 Our study focused on presential exams and consultation, and some other studies21 found that although patients were severely affected by fear of COVID-19 and its consequences, they sensed they still needed to undergo the exams.
Our study has several limitations, namely the small sample size, our instrument that was not validated for the Portuguese population, and it was only used in this one setting. Also, some aspects of the design of the study, namely not having a pre-exam evaluation also limited our study. This information would help us gather a more realistic view of how patients felt and dealt with this situation. Also, our study did not contemplate the possibility of the results of the exams affecting patients’ satisfaction. A future study on this topic would be of great interest and we will take it into consideration for future studies.
In the future, more studies should be done in this field, specifically longitudinal studies, to help us comprehend how patients cope with these situations, and how their health is affected on the long term.
Conclusion
The current pandemic context potentiates a feeling of insecurity, tension and distrust in patients, who end up hesitating to perform important exams. Some of the measures implemented make communication difficult, affecting the relationship with health professionals, and the feeling of security and well-being.
However, the measures instituted and the attitude of the unit's health professionals managed to convey security and tranquillity in the performance of the exams, promoting a good level of user satisfaction.
