Determinants of Patient Satisfaction with Health Care: A Literature Review

1. Introduction

Satisfying patients' needs is the first step toward having loyal patients. For a long time, the understanding of the relationship that exists between satisfaction and service quality was a key issue in determining development strategies in the health sector. Donabedian (1980), identified the importance of patient satisfaction so well that his work later became the basis for further research on health care. In this sector, the importance of measuring patient satisfaction has been clearly defined (Lin and Kelly, 1995), as it has been measured and studied extensively as an independent factor but also as a component of the quality of health products (Heidergger et al., 2006), and often in special cases also as an important factor in studies on the evaluation of the quality of the health service. Patient satisfaction has begun to be seen as a product of service quality which also affects clinical outcomes, economic measures and quality of life (Heidegger et al. 2006). The very fact that we have many opposing opinions, satisfied authors or not, shows by itself that the measurement of satisfaction is too complex and regardless of whatever result is concluded, we will still encounter dissatisfaction.

To demonstrate the unresolved conceptual difficulties related to the structure of satisfaction, in the literature it has been defined as: summation between psychological state and specific situations (Oliver, 1989), discrepancies between expectations and actual performance (Yi, 1990), composition of two components together, both emotional and cognitive, as a fulfilling response and a creation of experience (Oliver, 1989), a response to both the process and the end result (Hill, 2003).

Risser (1975) considers patient satisfaction as the degree of convergence between the expectations patients have of ideal care and their perceptions of the care they actually receive. Lochoro (2004) supports this view and also points out that satisfaction corresponds to the gap between expectations and perceived characteristics of a service. Howard and Sheth (1969), explain consumer satisfaction as a cognitive response of consumers. Churchill and Surprenant (1982) define consumer satisfaction based on the cognitive and emotional dimensions of the concept. Later, Oliver (1997) outlined various definitions of customer satisfaction that acknowledged their emotional impact on desired products or services. Mutava et al. (2006) pointed out that the product or service itself is one of the main factors in achieving customer satisfaction, defining it as a system through which the consumer passes for a given value of money.

It is very important to distinguish between interpersonal care and patient satisfaction. Patient satisfaction is usually measured and considered as an indicator of the quality of medical service (Cleary, Mc Neil, 1988). For this, it is necessary to specify the interpersonal aspects of a high quality of service and to ask patients about these experiences. It may also be useful to measure the extent to which care meets patient expectation, always bearing in mind that high satisfaction does not necessarily correlate with the delivery of high quality care (Cleary, et al., 1991). Shi and Singh (2005), from the perspective of patient satisfaction, explain service quality in two ways:

Quality as an indicator for satisfaction, which depends on individual experiences on features such as medical service (comfort, dignity, privacy, security, autonomy in decision-making and attention to personal preferences).

Quality as an indicator of individuals' total satisfaction with life and perceptions of some medical interventions.

On the other hand, Safavi (2006) thinks that patient satisfaction depends on three basic issues of the health care system. They are patients' perceptions of the quality of care provided, skilled physicians and organizations capable of providing decent service. He reached at the conclusion that satisfaction with hospital service is driven by dignity and respect, speed and effectiveness of service delivery, comfort, information and communication as well as emotional support.

2. Methodology

A narrative review approach was used to achieve the purpose of this study. Out of 84 articles that were read electronically, only 60 of them were taken into consideration for this paper. The studies range in years from 1969 to 2019. No time restrictions were applied. The research instrument was a literature review by combining keywords such as patient satisfaction, health care, satisfaction theories, literature review. The literature was searched in databases such as Emerald, Medline/PubMed, Web of Science, ScienceDirect, Scopus. Inclusion and exclusion criteria were adopted. The articles were selected based on content such as research on patient satisfaction, determinants of patient’s satisfaction, health care services, patient’s expectations and experiences and theories on patient satisfaction assessment. As sources were reviewed, additional citations were found and explored. The purpose was to see which are the determinants of patient’s satisfaction and the theories most used to measure it, more applicable to the health sector.

3. Determinants of Patient’s Satisfaction

Most of the studies reported in the literature showed the relationship between demographic factors such as age, gender, health status and level of education with patient satisfaction, but the results of these studies are different.

Two studies, one followed in Scotland on patients treated on emergency department in hospital between February and March 2002, and the other in 32 tertiary care hospitals in the USA, both showed that male patients older than 50 years , who had stayed a short time in the hospital in a not very serious health condition, as well as those patients with a lower level of education, had reported higher levels of satisfaction compared to other groups of the population. On the other hand, a questionnaire developed in various accredited hospitals in Taiwan showed that characteristics such as age, gender, and level of education had very little influence on patient satisfaction and that patients with less severe conditions had higher levels of satisfaction. Even Nguyen et al. (2002) and Jenkinson et al. (2002) stated from their studies that the two strongest and most consistent determinants of satisfaction were old age and good health status. Meanwhile, two studies conducted in Norway in 63 state hospitals, on overall patient satisfaction and control variables such as age and gender, showed that these variables were not significant determinants of patient satisfaction at all.

In 2004, Otani et al. developed a questionnaire on hospitals in the USA to see the relationship between nursing care, medical care and the surrounding environment, and the overall satisfaction of patients, showing that all these factors were statistically significant and positively related to patient satisfaction, and nursing care had the greatest impact of these three factors. Research also showed that the courtesy and respect shown by medical staff also affects patient satisfaction, while the way of communication plays a secondary role. On the other hand, a study conducted in Ireland in 13 hospitals showed that effective communication and clear explanation of situations had the greatest impact on improving patient satisfaction (Sweeney et al. 2008). These studies showed the importance of the role of nurses, as the most important determinant in the overall satisfaction of patients.

Other studies showed that the interpersonal communication skills of doctors expressed in variables such as behavior, explaining situations, level of care, emotional support, respect for patients and their preferences, as well as involving patients in decision-making, were more influential factors than competencies, clinical and equipment and technology used, for increasing patient satisfaction (Chang et al. 2006; Andrabi 2012). Research conducted in the USA in various hospitals by Clever, Levinson and Meltzer (2008), also showed that the way of communication played an important role in patient satisfaction. The same results on communication, staff sensitivity and care were achieved by Carlson et al. (2015).

The study conducted in France by Nguyen et al. (2002), and studies conducted in South Korea by Chat et al. (2005), showed that the equipment and technology used were the ones that most affected patient satisfaction, and that the biggest problems came from the lack of these dimensions. Otani et al. (2009) in his study revealed that staff care is the most influential attribute, while Alrasheedi et al. (2019), reported that the greatest dissatisfaction was caused by the long waiting time at the reception and the prolonged time of registration in the hospital. Contrary to them, Jenkinson et al (2002), in his study showed that physical comfort had the highest degree of association with satisfaction, compared to other dimensions such as information, or emotional support.

Patient expectations as a determinant of satisfaction - Different patients have different expectations, based on their knowledge and previous experiences, and consequently these expectations tend to change as their experiences accumulate over time. Patients with low expectations generally have higher satisfaction rates (Jawaid M, et al. 2018). As a quality assurance measurement and evaluation tool, expectations make the concept of satisfaction even more complex. We distinguish three categories of patient expectations identified from the literature: 1) background expectations, which come as a result of knowledge gathered from readings or consultation processes, 2) interactive expectations, which come as a result of the exchange of information between the patient and the provider health care and 3) active expectations, which are created as a result of actions performed by doctors, in providing treatments or counseling in the past (Greenberg RP, et al. 2006).

From a study conducted in Pakistan, emotional support provided by staff, waiting time of no more than 30 minutes, and consultation time of no less than 20 minutes were the factors most involved in creating patient expectations (Naseer, 2012). These expectations are also influenced by patient characteristics such as age, sex and marital status, as well as psychosocial determinants (Siddiqui et al. 2011; Saleem T, et al. 2009).

Patient experiences as determinants of satisfaction - Patient experiences are a strong predictor of patient satisfaction. Almost all patient questionnaires conducted worldwide attempt to measure patient experiences in the health sector to improve the quality of service in this area. WHO uses the measurement of patient experiences in the health sector as an indicator of the accountability of the health care system.

The performance and consequently the accountability of the system is reflected in a general improvement of the health status of the people who have received the service, ensuring equity and efficiency, while protecting individuals from excessively high costs (WHO, 2009). The level and distribution of accountability is therefore an important determinant of patient satisfaction, related to the performance of the health care system. Responsiveness refers to the ways and environment in which patients were treated when they needed health care. Eight areas of patient experience define health system responsiveness, and all of them are positively related to patient satisfaction.

Other determinants of patient experiences that affect patient satisfaction have also been determined from other studies. Thus, lack of beds, long waiting time at the reception and prolonged administrative procedures, unavailable medical staff, lack of basic medical equipment, cleanliness of rooms have also proved to be as determinants of patient satisfaction (Sajid, Rashid, 2008). Also, focus on the patient, which includes the time dedicated to the patient by the staff, the listening skills of doctors and nurses, the way of communication, has been proven to have a positive relationship with patient satisfaction (Karim, 2003). Lack of autonomy, ineffective communication and non-immediate service are some of the main factors leading to patient dissatisfaction (Oliveira, 2012). We can say that patient trust and doctors' communication behavior and waiting time were more strongly associated and positively affect patient satisfaction with the service received (Chandra, 2018).

Other factors that affect patient satisfaction are the continuity of health care provision and the proximity of health centers to residential areas or work centers (Thornton 2017). Having a hospital center far from the place of residence makes it difficult to attend treatment regularly and leads to unsatisfied patients.

Failure to meet patient expectations also affects satisfaction levels. On one hand, most patients have their own specific expectations about health care services (Kravitz, et al., 1996; Greene, et al., 1980; Sanchez-Menegay and Stalder, 1994; Lazare and Eisenthal, 1997) and on the other hand physicians, not being in aware of these wishes, often fail to provide the right service, causing in most cases dissatisfied patients.

4. Measuring Patient Satisfaction

Patients, in general, receive various health care services and judge the services provided (Choi et al. 2004). Questionnaires on patient satisfaction have been used to examine quality in health care and have proven the positive or negative relationship of satisfaction with service quality (Brady and Robertson, 2001; Gotlieb, 2000; Rust et al. 1994; Andaleeb, 2007).

Regarding the measurement of patient satisfaction, there are also different opinions in the literature. The best way to measure satisfaction is questionnaires, which have been used very successfully for more than 30 years. Howthorne (2006) after reviewing the literature related to patient satisfaction, concluded that none of the instruments used to measure it could be considered satisfactory.

Major theories on patient satisfaction assessment were published in the 1980s, and later Howthone (2006) synthesized more recent theories that were "restatements" of these assessments.

The Discrepancy and Transgression Theory by Fox and Storms (1981), advocated the idea that as patients' orientations to health care change, so do the conditions of care providers; if the orientations of the patients and the conditions offered are in harmony (match), then the patients are satisfied, if not they are dissatisfied.

The Expectancy-Value Theory of Linder-Pelz (1982), assumed that satisfaction was a combination of beliefs and personal values ​​about care as well as prior expectations about it. They identified the importance of the relationship between expectations and the variance in the evaluation of satisfaction by offering an operational definition of satisfaction as "positive evaluations on various dimensions of health care". In 1983, Pascoe further developed this theory, taking into account the influence of expectations on satisfaction, and then Strasser (1993), based on this theory, developed the model with different psychological factors, which were: formation on cognitive and emotional perceptions, form multidimensional, dynamic process, iterative response behavior and improvement from individual differences.

The theory of Ware et al. (1983) based on determinants and components, which presents patient satisfaction as a function of the patient's subjective responses to health experiences, influenced by personal expectations and preferences.

Multiple Models Theory by Fitzpatrick and Hopkins (1983), according to which expectations are mediated by social factors, reflecting the patient's health goals and the degree to which the illness or health care affects the patient's personal feelings.

Donabedian's (1980) theory of health care quality states that satisfaction was the primary outcome of the interpersonal process of care. He argues that the expression of satisfaction or dissatisfaction is a judgment of the patient on the quality of the service in all its aspects, but especially in relation to the interpersonal components of care.

Brady and Cronin (2001) proposed a hierarchical model to measure satisfaction considering the primary dimensions such as: interactive quality, quality of the physical environment and quality of the results obtained. Some authors showed that studies on patient satisfaction have a real impact on the behavior and habits of health professionals and are likely to stimulate improvement measures in the health service (Greco et al. 2001). A study conducted in France reported that among doctors of a university hospital, 94% of them had a positive opinion on patient satisfaction studies, 60% of them were aware of the results of these studies in their departments, and 40% reported that these studies brought about improvements in service and even modified their own behavior (Boyer et al. 2006).

Aragon et al. (2003) conducted a research in the emergency department of different hospitals and suggested that the main theory for measuring patient satisfaction depended on the measurement of latent variables such as: medical service, waiting time and nursing care. These variables define according to him the characteristics of the quality of health care. They proved that the overall satisfaction of the patient depends on these three variables and that satisfaction is also positively related to two other indicators such as: the desire to recommend the hospital and the degree to which the service justifies the payments made by the patient.

Kano (1979) develops the 'M-H property of quality' by adapting the work of Herzberg et. al.'s (1959) 'Motivation-Hygiene Theory'. He suggest a two-way model on quality based on customers' perception and experience. The Kano model proposes that the relationship between performance of attributes and customers' satisfaction is non-linear. Kano considered five quality elements: Attractive Quality Elements, One-dimensional Quality Elements, Must-Be Quality Elements, Indifferent Quality Elements, Reverse Quality Elements.

CAHPS (Consumer Assessment of Health care Providers and Systems) is another instrument used to measure patient satisfaction and its relationship with service quality. It is a valid international tool for measuring satisfaction, focusing on assessing patients' actual experiences during care, without measuring their expectations.

All of the above methods of measuring patient satisfaction suggested that service quality is one of the main predictors of overall patient satisfaction.

5. Conclusion

In conclusion, from the review of the literature on the factors that influence patient satisfaction in summary, we can say that patients are more satisfied with the health service if these health systems are responsible in terms of dignity, autonomy, prompt service and achievement of patient expectations. Patient expectations, which are influenced by patient characteristics such as age, gender, social class, education, and less so by gender and ethnicity, are very important predictors of patient satisfaction in many important studies. However, patient perceptions and other psychological factors are also potential determinants and should not be neglected.

Patient characteristics such as age, gender, education, ethnicity, marital and socioeconomic status have been widely used to measure patient expectations (Bleich S, et al. 2009). Patient factors that influence their expectations of health care are: older age, male gender, low socioeconomic status, and education, which have been shown to have a positive relationship with patient satisfaction.

Older people have lower expectations and are therefore more satisfied with health care than younger people. They expect less information from doctors and tend to accept treatments more easily than younger people. Gender has been labeled as an inconsistent predictor of patient satisfaction, but the trend is that women are less satisfied with the health service compared to men. High expectations and greater experiences are thought to be the reasons for this result (Sultana A, et al. 2010).

Communication is also an extremely important element that affects patient satisfaction. If the patients did not feel well informed, close to the doctors or unclear about their health status, this could also affect the process of their recovery. Therefore, correct communication and establishment of good cooperative relations, play an important role in increasing patient satisfaction. In particular, patients expect doctors and nurses to communicate clearly, in a friendly manner, and to properly explain test results, diagnoses, medication, health regimens, etc. On the other hand, nurses must also understand patients' problems well and communicate them correctly to doctors. It has already been proven that the better the quality of communication perceived by the patient, the higher their level of satisfaction (Andaleeb, 2010). Patient expectations of health care providers and the health system in general play an essential role in the concept of patient satisfaction. Patients compare their experiences in this sector, with their expectations on this service, allowing the providers of this service to measure their satisfaction (Constantino et al. 2011).

References