Today, emergency departments are the main sector to provide healthcare to critical conditions, like Ischemic Heart Disease (IHD) patients (Tanabe et al. 2004). Every day a significant number of patients with severe heart disease or similar causes of myocardial infarction refer to the emergency department with the hope of surviving life-threatening conditions (Messina et al. 2015). The increased number of patients in this ward, along with the concurrent admission of IHD patients, has led to population crowding in the emergency rooms (Tanabe et al. 2004). 
Emergency department congestion leads to prolonged waiting time for receiving care. Increased waiting time and prolonged emergency care delivery could reduce the quality of care and increase adverse outcomes in ischemic heart patients with life-threatening conditions (Henneman et al. 2010). As a result, addressing these patients’ satisfaction in the emergency department may improve the quality of the care provided (Lee et al. 2008).
Patient satisfaction has emerged as a central focus of healthcare delivery during the last decades, and nursing care has become one significant component of patient satisfaction (Atallah et al. 2013). Patient satisfaction with hospital services and the balance between the perceived and expected care (Akhtari-Zavare et al. 2010), are major principles that should be considered, especially in the emergency department. Besides, patient satisfaction evaluation has become increasingly important for healthcare organizations (Shamsi et al. 2016; Sun et al. 2004; Welch 2010); it can only be understood through individuals’ expression of their inner perceptions (Johansson, Oleni & Fridlund 2002; Suhonen et al. 2012). 
Patient satisfaction is critical in emergency departments. Every year, approximately 6 million patients with chest pain visit emergency departments. Moreover, this condition has been identified as the second leading cause of seeking emergency services in the United States (Walker, Galuska & Vega 2010). However, increasing population growth has reduced patient satisfaction with emergency care (Suhonen et al. 2012). Other factors, such as the inadequate number of beds and the long wait to receive care and medical interventions, could also affect patient satisfaction (Kulstad et al. 2010). Nurses are the main care providers and have the greatest interaction with hospitalized patients. Consequently, not only can nursing care play a crucial role in patient satisfaction with the provided care (Tang, Soong & Lim 2013), but it can also be used as a strong indicator in examining patient satisfaction (Brown et al. 2005; Fontova-Almató et al. 2019).
Patient satisfaction is beneficial in determining patients’ needs and the quality of the provided services, comparing hospitals, identifying organizations with more effective performance, and the areas which require improvement. It can also be used to clarify healthcare policies in different organizations (Bredart et al. 2007; Olshaker 2009; Tang et al. 2013). Research has indicated a desirable level of satisfaction among cardiac patients, i.e.  the majority of these patients have been highly satisfied with nursing care (Boulding et al. 2011; Legesse & Walle 2016; Siebens et al. 2010). Lee et al. reported that most patients with a heart attack were satisfied with the care provided (Lee et al. 2008). In addition, proper care increased patient satisfaction after angiography (Sampson, O’Cathain & Goodacre 2009). However, Tang et al. found that patients were only moderately satisfied with the received care (Tang et al. 2013). 
Related studies in Iran have suggested different results. According to Ghamari et al. most patients in coronary care units had moderate satisfaction with nursing care (Ghamari et al. 2008). While Shaikhi et al. reported a high level of patient satisfaction (Sheikhi & Javadi 2004), Jolaee et al. (Joolaee et al. 2011), and Eshghi et al. (Eshghi et al. 2016) found moderate to low satisfaction in this group.
IHD patients face life-threatening situations and require urgent medical treatment (Henneman et al. 2010); thus, assessing satisfaction with the care provided in these patients could reflect the quality of emergency care provided. Accordingly, the current study sought to identify the existing status and understand the gaps in the healthcare system by investigating the level of satisfaction with emergency nursing care in patients with IHD who have referred to the emergency department of an educational Hospital in Iran, in 2017.
2. Materials and Methods
This cross-sectional study was conducted on 610 patients with IHD who were hospitalized in the emergency department of an educational Hospital in Iran during April-October 2017. According to the Cochran formula, the sample size was calculated as 607 patients (z=1.96; P=82.8; and d=3); however, it was considered equal to 610 patients for further assurance. The study subjects were randomly selected using a table of random numbers.
The inclusion criteria were minimum emergency department stay of 12 hours due to IHD, minimum age of 18 years, Iranian nationality, willingness to take part in the study, ability to speak and understand Persian, no hearing or speech impairment, full consciousness, and hemodynamic stability. Moreover, incomplete questionnaires were excluded from the study. 
The required data were collected with a two-part questionnaire comprising demographic characteristics (age, gender, marital status, educational level, economic status, occupation, and the history of hospitalization) in the first part and the Patient Satisfaction Inventory (PSI) in the second. The PSI was designed by Hinshaw and Atwood (1981) and reported to be valid and reliable (Cronbach’s alpha coefficient= 0.9) by Rafii et al. (Rafii, Hajinezhad, & Haghani 2009). It comprises 25 items in three subscales of technical-professional care (7 items), trust (11 items), and patient education (7 items). The questions are scored on a five-point Likert-type type scale from completely agree (5) to completely disagree (1). While 14 items are positively scored, others have negative scores. Consequently, the total obtainable score ranges from 25-125. Scores ≤69, 70-104, and ≥105 indicated dissatisfaction, satisfaction, and high satisfaction, respectively.
The collected data were analyzed in SPSS at a significance level of 0.05. As the normality test revealed the normal distribution of all data, parametric tests were applied. Independent Samples t-test was used to assess the relationships between some independent categorical variables (gender, marital status, and a history of hospitalization) and mean patient satisfaction value. The relationships of other independent categorical variables (educational level, occupation, and income) with mean patient satisfaction scores were evaluated using the Analysis of Variance (ANOVA). Pearson’s correlation analysis was performed to investigate the relationships between quantitative variables. Finally, Multivariate Regression Analysis was applied to determine the factors affecting patient satisfaction.
3. Results
Of 610 distributed questionnaires, 600 were completed and analyzed (response rate=98.36%). The majority of the study participants (n=304; 49.3%) were male, and their Mean±SD age was 47.99±14.37 years (Table 1). The total Mean±SD score of patient satisfaction with nursing care was 71.90±14.76. On the subscales of trust, patient education, and technical-professional care, the mean scores were 3.92±0.90, 3.17±0.74, and 4.40±1.09, respectively. 

Among the three subscales of patient satisfaction, the highest and lowest scores were related to technical-professional care and patient education, respectively. Independent Samples t-test results suggested no significant relationship between mean satisfaction scores and either gender or marital status (P>0.05). However, there was a significant relationship between mean scores of patient satisfaction and a history of hospitalization (P=0.03), i.e.  mean satisfaction was higher among the study subjects with a history of hospitalization. Pearson’s correlation analysis results revealed a positive and significant correlation between age and satisfaction scores (P<0.01; r=0.310).
ANOVA results indicated a significant difference between mean satisfaction and educational level. Tukey’s posthoc test suggested a significant difference between illiterate patients and those with a high-school diploma or higher degrees. In other words, illiterate participants had significantly higher levels of satisfaction (P=0.01). Meanwhile, the relationships between mean patient satisfaction and occupation or income level were not significant (Table 2).

As per Table 3, with df(7, 192), P= 0.002, and level of significance of 0.05, demographic variables could predict patient satisfaction with nursing care. Based on the obtained value for the coefficient of determination (R2), demographic variables could explain nearly 11% of changes in patient satisfaction. Considering the t and P values for demographic variables, only age impacted patient satisfaction; higher age was associated with greater satisfaction with nursing care.

4. Discussion
In the current study, individuals with IHD in the emergency department had the highest level of satisfaction with technical-professional nursing care. Ali et al. reported that cardiac patients were relatively satisfied with their nursing care (Ali et al. 2017). Wolf et al. (Wolf et al. 2008) and Rafii et al. (Rafii, Hajinezhad & Haghani 2008) reported similar results. In other words, nurses were highly skilled in performing procedures; therefore, patients were satisfied with their conducted procedures. Some studies in Iran also reported that patients described the nurses’ skill in performing procedures well (Hajian 2007). Greenslade et al. believed that nurses pay more attention to this aspect of care and often try to perform it more accurately (Greenslade & Jimmieson 2011).

Among all the subscales of patients’ satisfaction, our study participants were least satisfied with patient education. The findings of Wolf et al. (2008), Rafii, Hajinezhad & Haghani (2008), and Joolaee et al. (2011) were consistent with ours. Likewise, Farahani et al. (2013), Oterhals et al. (2006), and Ghamari Zareh et al. (2008) highlighted the dissatisfaction of patients with education after the diagnosis of cardiac diseases. In addition, Safari et al. reported that a small number of patients were satisfied with the quality of educational services in the Coronary Care Unit (CCU) (Safari M, Unpublished thesis, 2002).
Meanwhile, nursing studies have considered patient education as a crucial field of nursing and an inseparable part of patient care that can substantially influence patient recovery (Farsaei et al. 2011; Kalisch, Landstrom, & Hinshaw 2009; Suhonen et al. 2012). However, nurses are often unable to perform this duty due to huge technical-professional load, inadequate information about the methods of patient education, frequent shift change, insufficient pay, dissatisfaction with nursing profession, and the lack of time (Aghakhani et al. 2012; Kiani, Balouchi, & Shahsavani, 2016). Besides, the undergraduate nursing curriculum in Iran assigns only one credit hour for patient education, which is far below the standard (Azizi-Fini et al. 2012); thus, insufficient training can be responsible for low patient satisfaction.
The present study highlighted a significant relationship between education and satisfaction levels, i.e.  illiterate patients were more satisfied with nursing care (probably due to their lower expectations). While this is in line with the results obtained by (Joolaee et al. 2011; Lee et al. 2008; Bredart et al. 2007; Azizi-Fini et al. 2012) stated that patients with higher education levels were more satisfied with nursing staff (Azizi-Fini et al. 2012). Differences in research settings and culture could explain the conflicting results of these studies.
According to our findings, patient satisfaction increased with aging. Messina et al. also agreed that older individuals were more satisfied with the provided care (Messina et al. 2015). In contrast, Tang et al. found no relationship between age and patient satisfaction (Tang et al. 2013). Jaipaul et al. concluded that satisfaction level increased up to the age of 65-80 years and reduced afterward (Jaipaul & Rosenthal 2003). Therefore, a higher age may reduce people’s expectation of care and make them satisfied, even with moderate quality of care.
Additionally, older patients have a history of hospitalization. We observed a significant relationship between patient satisfaction and a history of hospitalization; thus, the experience of hospitalization could affect patients’ satisfaction by increasing their familiarity with nursing services and other issues within the ward. Similarly, Thrasher et al. argued that patients with previous experience of nursing care expressed higher levels of satisfaction with nursing services (Thrasher & Purc-Stephenson 2008). These two findings mutually inform one another.
Performing the study in only one hospital and the cross-sectional nature of the study were among the limitations of this study. Therefore, future studies are recommended to evaluate larger samples over longer periods and in a greater number of health centers.
Patient satisfaction with nursing care was at a desirable level in this study. However, patient satisfaction with education was low. The achieved results highlighted the necessity to examine the current provision of in-hospital information and education to IHD patients. Thus, nursing managers should organize educational courses and motivate nurses to prepare the contexts for increased quality of care and improved patient education to IHD patients. An educational program for nurses can be beneficial in this regard. Many of these patients are readmitted due to a lack of knowledge; therefore, health policymakers could provide an opportunity for patient education by increasing the number of nursing staff in hospitals.
Ethical Considerations
Compliance with ethical guidelines
Before data collection, the necessary permissions were obtained from Kashan University of Medical Sciences, the Research Ethics Committee, and hospital authorities (Ethical Code:1141). Moreover, the study participants provided signed informed consent forms after receiving explanations about the study objectives. They were then requested to carefully (but anonymously) complete the questionnaire in the presence of the researcher. The items of the questionnaire were read to illiterate patients, and their responses were precisely recorded. All study subjects were reassured that the study results would not affect their treatment process.
Funding
This article was part of a research thesis (number 9117). All of the patients who cooperated in the research by completing the questionnaires is highly appreciated.
Authors' contributions
Conceptualization, Investigation: all author; Methodology, writing – review & editing, and supervision: Mohsen Adib-Hajbaghery, Ismail Azizi-Fini, Fatemeh-Sadat Izadi-Avanji; Writing - original draft: Masoumeh-Sadat Mousavi, Mohsen Adib-Hajbaghery, Ismail Azizi-Fini; Funding acquisition, resources: Ismail Azizi-Fini.
Conflict of interest
The authors declared no conflicts of interest.
Acknowledgments
The authors are grateful to Kashan University of Medical Sciences for their financial support.


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