the continuum of patient satisfaction—from satisfied to very satisfied
TRANSCRIPT
Social Science & Medicine 57 (2003) 2465–2470
Short report
The continuum of patient satisfaction—fromsatisfied to very satisfied
Karen Collins*, Alicia O’Cathain
School for Health and Related Research (ScHARR), University of Sheffield, Regent Court, 30 Regent Street, Sheffield S1 4DA, UK
Abstract
In a move towards a more informed understanding of the concept of satisfaction, this paper aims to explore how 30
dermatology patients describe what it meant to them to be either satisfied or very satisfied with their healthcare. This
was undertaken using in-depth interviews and the findings suggest that participants clearly differentiated between being
satisfied or very satisfied with healthcare. While for some participants, being satisfied with healthcare was described in
terms of care being adequate or average, for others it meant that there were aspects of healthcare that could be
improved, or that something was missing and that optimal care was not achieved. Care and management had been
‘acceptable’ or ‘sufficient’ but not ‘outstanding.’ In contrast, being very satisfied with particular aspects of healthcare
was described in ways that suggested that the service was not only more than adequate, but ranged from ‘better than
average’ to ‘outstanding’, i.e. optimal care had been provided. This observation of a ‘continuum of satisfaction’ has
specific and important implications for the future analysis and presentation of patient satisfaction surveys. It is
suggested that attention to the differences between the two constructs provides a useful means to highlighting areas of
patient concern and that researchers reporting the results of patient satisfaction surveys should cease to collapse them.
r 2003 Elsevier Science Ltd. All rights reserved.
Keywords: Patient satisfaction; UK
Introduction
Successive UK Governments have continued to stress
the importance of the quality of patient experience and
responding to patients’ views of services (NHS Manage-
ment Inquiry, 1983—‘The Griffith Report’ (DoH, 1983);
Working for Patients (DoH, 1989); The Patient’s
Charter, (DoH, 1991); Patient and Public Involvement
in the NHS, (DoH, 1999); the NHS Plan (DoH, 2000).
Although there are a variety of approaches to elicit
patients’ views of healthcare (Beverley et al., 2001), a
frequently used means has been the patient satisfaction
survey (McIver & Meredith, 1998; Coyle, 1999). How-
ever, despite the growth of patient satisfaction research
over the last 20 years, studies have been subjected to a
substantial degree of criticism, particularly relating to
the lack of understanding of the nature and definition of
the concept (e.g. Williams, Coyle, & Healy, 1998;
McIver & Meredith, 1998; Baker, 2001). A further
criticism has been that most surveys have tended to
typically report high undifferentiated levels of patient
satisfaction, with very few patients expressing dissatis-
faction (Locker & Dunt, 1978; Wilkin, Hallam, &
Doggett, 1992). Hall and Dornan’s (1990) meta-analysis
of satisfaction found average satisfaction levels to be
76% across more than 200 studies, and Fitzpatrick
(1991) identified that at least 80% of respondents
express satisfaction for any given question. Several
qualitative studies have reported that although high
levels of satisfaction were expressed on standardised
patient satisfaction surveys, in-depth interviews indi-
cated negative experiences and perceptions not reflected
in the questionnaires (Bruster et al., 1994; Williams et al.,
1998; Dougall, Russell, Rubin, & Ling, 2000).
Despite the difficulties surrounding the understanding
of patient satisfaction, there is no doubt that patient
ARTICLE IN PRESS
*Corresponding author. Tel.: +44-114-222-0699; fax: +44-
114-222-0798.
E-mail address: [email protected] (K. Collins).
0277-9536/03/$ - see front matter r 2003 Elsevier Science Ltd. All rights reserved.
doi:10.1016/S0277-9536(03)00098-4
satisfaction surveys are valued by those funding and
undertaking research and that their use will continue.
Therefore, alongside the need to define and understand
patient satisfaction, we must also be able to interpret the
results of patient satisfaction surveys. Some researchers
have focused on the high reported levels of patient
satisfaction as a way of making sense of this difficult
area. Williams et al. (1998) have found that many
expressions of satisfaction hid a variety of reported
negative experiences due to the perception of culpability
and the boundaries of duty. This led them to recom-
mend that surveys should focus on patient experiences
rather than on evaluation of services or that attention
should be paid to dissatisfaction rates rather than
satisfaction rates in such surveys; this latter recommen-
dation was earlier proposed by Carr-Hill (1992). Yet,
before we abandon patient satisfaction surveys for
patient experience surveys, or one end of the spectrum
of satisfaction for the other, there might be further value
in exploring different meanings patients attach to
degrees of satisfaction. After all, satisfaction surveys
make use of five-point Likert scales rather than a
dichotomy of satisfaction versus dissatisfaction. Do
patients themselves make a distinction between being
satisfied and very satisfied? and if so, what leads them to
do so?
Methods
Sampling and recruitment
Data presented here were collected as part of a
randomised controlled trial of telemedicine in dermatol-
ogy (Bowns, Collins, Walters, & Calvert, in press). It
was conducted between a locality group of eight General
Practices in Sheffield and a single teaching hospital in
Sheffield that provided the local dermatology referral
service. Ethical approval for the trial was gained from
the Local Research Ethics Committee.
Participants were recruited to the trial by their general
practitioners. They had to have been referred with a new
problem or not seen by the hospital dermatologist in the
preceding 12 months, be aged 16 years or over, and be
judged by the general practitioner to require a conven-
tional out-patient consultation with a National Health
Service hospital consultant dermatologist. People with
particular dermatological problems, mental illness or
handicap or language barriers unrelated to the skin
problem, or who wished to consult a specialist derma-
tologist privately were excluded. Participants were asked
to complete a patient satisfaction questionnaire, at the
end of which they were asked to indicate whether they
would be willing to be contacted to discuss being
interviewed about their recent experiences of the
healthcare they had received. The overall response rate
to the questionnaire was 74% (n ¼ 128=173). Of these,56% (n ¼ 72=128) patients stated their willingness to be
interviewed. Rather than sample purposively or theore-
tically, KC interviewed the first patients who agreed to
take part in an interview. The interviews continued
consecutively until ‘saturation’ was reached (Rubin &
Rubin, 1995).
Thirty participants were interviewed in total: 12 men
(seven from the telemedicine group, five from the control
group) and 18 women (13 from the telemedicine group,
five from the control group). Their ages ranged from 16
to 82 years. Twenty-eight participants classed themselves
as ‘white’ European, one as Afro-Caribbean and one as
Asian. No formal assessment of socio-economic status
was undertaken. However, typically the participants
reflected the working rather than unemployed popula-
tion, and were in manual rather than nonmanual
occupations. The participants interviewed were recruited
from all the eight participating practices, although the
practice where access was negotiated first represented
34% (n ¼ 11) of all the participants interviewed. The
participants presented to their GPs with a range of
dermatological problems, which included rashes-itchy/
painful or tender (16), gradual/sudden hair loss (2),
lesion(s) growing/bleeding or painful (12). Seventeen of
these participants reported being very satisfied with their
care and management on the patient satisfaction survey,
nine reported being satisfied, three as neither satisfied or
dissatisfied, and one as dissatisfied.
The interviews
Interviews were conducted, in most cases, within 1
month of the individual’s consultation. They were all
tape-recorded and transcribed verbatim. The interviews
focused on participants recent healthcare experiences
and during the course of the interview each participant
was asked to describe what the term being satisfied with
healthcare meant to them, and whether there was a
difference between being satisfied as opposed to very
satisfied with their healthcare. The interviews varied in
length, ranging between 30min and 2 hours.
Data analysis
The data were analysed using interpretative phenom-
enological analysis (IPA) (Smith, 1996). The analytical
stages of IPA included reading each transcript a number
of times and writing down initial thoughts. Working
through these more closely, emerging themes that
captured the essential quality of what was being found
in the text were identified. At this point, initial themes
were then grouped together into subordinate themes.
The above stages were carried out with all 30 interviews.
As new themes emerged in subsequent interviews, these
were analysed against earlier transcripts. These emerging
ARTICLE IN PRESSK. Collins, A. O’Cathain / Social Science & Medicine 57 (2003) 2465–24702466
subordinate themes were then integrated ‘in order to
identify shared themes which captured the essence of the
participants experiences’ (Willig, 2001, p. 61).
Findings
Individual participant descriptions of satisfaction
emphasised the importance of receiving a diagnosis,
treatment and cure; minimum waiting time for appoint-
ments and treatment; the need to receive adequate
information and explanations; receiving individualised
personal care, including the need to be taken seriously;
and the importance of practitioner characteristics and
good communication. The emergent nature of satisfac-
tion, which was defined, redefined and re-evaluated by
participants throughout the interview process has been
reported in detail elsewhere (Collins & Nicolson, 2002).
This paper focuses upon the identification of differences
between the state of feeling satisfied and very satisfied
with healthcare.
Descriptions of care
Participants were able to distinguish between services
they were satisfied with and those they were very satisfied
with. A wide variety of words, metaphors and similes
throughout the interviews used by participants helped to
particularise these differences (Table 1).
Three themes emerged which were significant in
delineating the continuum from satisfied to very satisfied.
These were (1) the manner of treatment received, (2) the
sense of incomplete treatment and management, and (3)
the adequacy of management. The presentations of these
themes are illustrated with extracts from the verbal
accounts of participants that were chosen for their
pertinence to the themes and for being especially
representative of all the participant accounts. In order
to contextualise the quotations, the participants’ gender,
age and group are provided.
Manner of treatment received—‘it ain’t what you do it’s
the way that you do it’
Participants described feeling satisfied when they had
received treatment that had resulted in their condition
improving or being ‘cured’. However, the way in which
care and treatment had been given was an important
factor in determining whether they were likely to feel
satisfied or very satisfied with their experience.
Well I think it’s to do with the way you’ve been
treated when you’re there as well as being managed
and having your treatment (Interview 30: man, age
38, telemedicine group).
Participants described being satisfied as meaning that
their problems had been managed or ‘treated,’ but in
order to feel very satisfied with their healthcare
experience, although the treatment was perceived to be
the same, there was a sense that there was that ‘little bit
extra.’ Extra effort was described in terms of an
individualised and personal approach. The following
participant’s account is quoted at some length because it
is both typical and pertinent to many of the participant
accounts of being satisfied or very satisfied in terms of
the way in which their care was managed:
Well satisfied is just that it’s the system you know just
as it goes along. You know ordinary run of the mill
system. You go and its neither here nor there you
know. You go and they say right take these tablets
and come back next week or something you know
that’s just an example, I mean that’s just being
satisfied you know you’ve been treated. Very satisfied
is when there seems to be that bit of extra effort put
in and makes you feel that they do really care or the
system is set up for you. It’s not just a production line
sort of thingy (Interview 20: woman, age 39,
telemedicine group).
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Table 1
Terms used within participants descriptions of differences between being satisfied as opposed to very satisfied with healthcare
Satisfied Very satisfied
Alright Outstanding
Ok, some way to go before perfect Brilliant
Just happy—still a long way to go run-of-the-mill Great
Not going overboard about it Spot on
Not ecstatic but not pulling it down middle of the road Better than average
Always element that can be improved or changed Good as opposed to alright
If one thing missing New idea
If doubtful Very confident
Managed up to a point Problem sorted
Still concerns Perfect
A bit miffed about something Someone putting in more effort
In that I am 90% or 99% may be sure given best treatment No niggles
K. Collins, A. O’Cathain / Social Science & Medicine 57 (2003) 2465–2470 2467
Participants felt very satisfied when doctors attempted
to understand their experiences. They appreciated time
to discuss their thoughts and feelings with the doctor.
They wanted to feel able to ask questions and to be able
to fully explain their symptoms. This type of interaction
is characteristic of the patient-centered approach (Riv-
adeneyra, Elderkin-Thompson, Cohen Silver, & Wait-
zkin, 2000) and has previously been linked to patient
satisfaction (Kinnersley, Stott, Peters, & Harvey, 1999).
Sense of complete treatment—‘nothing missing’
Participants used words such as ‘adequate’ ‘accepta-
ble’ and ‘okay’ to describe their feelings of being satisfied
with the healthcare they had received. However, they
spoke of it with a sense that there was still an indefinable
something ‘incomplete’ or ‘missing’ from the care and
management. The sense of ‘nothing missing’ was
articulated as being left with no outstanding or
unresolved issues on completion of their healthcare:
That it had been managed up to a point but I’d still
got some concerns, or there’s still some way to go
before it’s perfect (Interview 17: man, age 72, control
group).
Well I think if I’m very satisfied then I’ve come home
feeling good. I’ve not got any little niggles you know,
I can come home and I’m not niggled about
anything. I think being satisfied I’m probably a little
bit miffed about something (Interview 22: woman,
age 56, telemedicine group).
Adequacy of treatment—‘room for improvement’
Unlike the previous participants, for whom the
differential between being satisfied and very satisfied
was defined in terms of ‘something missing’ from the
healthcare experience, the following participants were
very precise in their definition of being very satisfied; it
was the experience of management and care being
outstanding:
Well it just depends whether that I think the person
or people that treated me was outstanding in my own
mind. New ideas of how I could have helped myself,
and treatment like my GP never tried on me. I’d have
thought he’d have given me better ideas on how to
overcome it or what to do to help myself. Then I
would have said I’d have been very satisfied because
I’d got new ideas in my brain that I could help myself
(Interview 1: male, age 64, telemedicine group).
Participants used phrases such as ‘middle-of-the-road’
or ‘run-of-the-mill’ to describe their sense of adequacy of
care and management when describing satisfaction.
Conversely, being very satisfied was only achieved when
participants perceived the service they were receiving as
being ‘better than average’:
You know satisfied is you know that’s ok. But I
thought it were very good so I’m very satisfied. Well
satisfied is kind of, it’s a bit like ‘run of the mill’ isn’t
it type of thing, but I thought the whole system were
a bit better than that. I thought it were sort of better
than average (Interview 20: woman, age 39, tele-
medicine group).
For several participants, feeling confident with aspects
of their healthcare was an important issue when deciding
whether they were satisfied or very satisfied with their
care. The following participant reported that although
she was satisfied with her care and management, she
‘didn’t feel totally confident’ implying that this would
have resulted in her feeling very satisfied:
Things like being confident that the consultant had
given the GP enough information for them to pass
the information back to me second-hand and I didn’t
feel totally confident that it had because of the nature
of the communication that came back to me.
(Interview 25: woman, age 40, telemedicine group)
There’s just no difference
Data inconsistent with emerging themes (Murphy,
Dingwall, Greatbatch, Parker, & Watson, 1998) were
incorporated within the analysis, but more specifically
negative-discrepant cases are presented below (Silver-
man, 2000). Despite most participants describing differ-
ences in being either satisfied or very satisfied, four of the
participants felt that there was no difference between the
two terms. There were no patterns in terms of age,
gender or randomised group to distinguish these
participants.
You know I think they’re so near to each other that
you can’t expect to see any difference (Interview 18:
woman, age 45, control group).
Another participant also highlights the arbitrary
nature of responses to satisfaction questionnaires:
I think its fairly arbitrary actually. I always find it
quite difficult doing those kind of questionnaires you
know where it lies. I mean I try to do it as well as I
could but it does feel a bit arbitrary at the end of the
day (Interview 12: woman, age 81, telemedicine
group).
Finally, one participant could differentiate in theory
but not in practice. He felt unable to assess the skills and
competence of the consultant because he felt he lacked
expertise (i.e. to know whether the diagnosis and
treatment given was the right one). This resulted in the
participant feeling satisfied rather than very satisfied.
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Discussion
The findings suggest that some patients distinguish
between the states of being satisfied or very satisfied with
healthcare, suggesting that the continuum of satisfaction
displayed within five-point Likert scales is meaningful to
some of the patients who complete satisfaction surveys.
They describe the distinction in different ways—for
some, being satisfied with healthcare was described in
terms of being adequate or average, for others it meant
that there were aspects that could be improved, or that
something was missing and that optimal care was not
achieved. Very satisfied meant that care was persona-
lised, nothing was missing, and was described as
‘outstanding’, a move into the schema of a personalised
and patient-centered approach.
We cannot say that all patients can and do distinguish
between these two categories of the continuum of
satisfaction. Within our sample there were examples of
patients who could not do so. There is also evidence in
the literature that even patients who evaluate a service as
very satisfied may identify problems with the service
(Williams et al., 1998). In addition, our sampling
strategy was biased towards patients who were willing
and able to complete a patient satisfaction questionnaire
and discuss it. Thus our sample was unlikely to include
people who find these questionnaires difficult and
unwelcome or who are likely to be part of the
acquiescent response set (Ware, 1978). Our focus was
on dermatology patients and did not reflect the spectrum
of patients and illnesses within the NHS and so may not
be generalisable across different healthcare settings or
patient groups. However, it is a group not too dissimilar
from a large proportion of users of the health service
such as those attending general practice and other out-
patient clinics. Further, the primary purpose of this
qualitative study was not to establish representativeness
or generalisability, but rather to reflect ‘the diversity
within a given population’ (Barbour, 2001, p. 1115) and
to generate new insights and understanding into the
concept of satisfaction. For all this, we can say that
enough respondents to patient satisfaction surveys can
articulate a difference between being very satisfied and
satisfied for us to consider the implications of it.
As we have already indicated, many studies of patient
satisfaction have tended to be survey based (McIver &
Meredith, 1998), and within such surveys, the coding
categories satisfied and very satisfied are frequently
collapsed or merged into one category during the
process of statistical analysis and reporting. Thus, a
typical result might be presented as: ‘96% of patients
reported being satisfied/very satisfied with their care.’
This observation of a continuum of satisfaction from
satisfied to very satisfied is missing from the related
literature and has specific and important implications
for future policy initiatives and directives. The NHS
documentation, ‘The NHS Plan; a plan for investment, a
plan for reform’ (2000) states that ‘most people in
Britain support the NHS and are broadly satisfied with
its overall performance.’ [24] The evidence from this
study would question such a statement. Such statements
as ‘broadly satisfied’ mask areas where improvement is
needed. Acknowledging potential differences between
being satisfied and very satisfied would be one useful
means to enable those interpreting satisfaction with
healthcare to understand where future healthcare could
be improved. It may be fair to say that with limited
resources the NHS aims to improve the health of the
nation by providing an adequate standard of care for the
majority rather than excellent care for the individual.
However, the position taken in this study suggests that
the NHS should aim to achieve optimum or excellent
standards of care for the majority, even though this may
be construed as idealistic. We would suggest that
distinguishing, rather than collapsing, the two categories
satisfied and very satisfied permit a more informed
understanding and insight into patients’ valuations of
health services. Additionally, it might largely explain the
discrepancy between findings from qualitative and
quantitative studies of patient satisfaction. The concept
very satisfied may itself be a standard which audit and
evaluation could aim for and thus reporting of very
satisfied against all other categories might be an
appropriate way forward for all those undertaking
future patient satisfaction surveys.
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