Patients evaluations of their health care: the expression of negative evaluation and the role of adaptive strategies
Introduction
Patients have become key players in the drive to evaluate the effectiveness, efficiency and acceptability of health care in the UK [1]. While the focus on patients as evaluators of health care has been welcomed, comparatively little effort has been placed on developing an understanding of the conceptual and methodological basis of patient evaluation, despite the recognition that there are problems with the concept of patient satisfaction [2], [3], [4], [5], [6], [7], [8]. As these studies highlight, an important limiting feature has been the poor conceptual and theoretical development of the concept of patient satisfaction and concerns about its validity. While there have been some attempts to develop a theoretical understanding of satisfaction [9], [10], [11], [12], [13], [14], [15], few of the ‘first generation’ studies, as we describe them, which predominantly examined correlational relationships between expectations and satisfaction, significantly enhanced our understanding of patient evaluation or provided a model to guide researchers in the development of methods that are sensitive to the ways in which patients evaluate their care. We identified a smaller number of ‘second generation’, mostly qualitative studies, that have undertaken more in-depth explorations, and have provided useful insights into the complexity of evaluation. They have highlighted the need to continue developing our understanding of evaluation, particularly in relation to how patients express their negative evaluations [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [16]. In summary, we still have a limited theoretical understanding of how patients evaluate their care, and methodologically, which is the best approach to use. In view of these conceptual and methodological difficulties, this study focused on exploring the nature of evaluation, particularly in relation to the ways in which patients expressed their negative experiences, in order to inform conceptual development and subsequent methodological development.
Section snippets
The sample
A sample of outpatients undergoing a range of procedures including endoscopy, general surgery or attending the breast clinic were selected as the study sample. The sampling strategy was determined by the underlying hypothesis of the study, which is, that patients varying in age and sex were likely to differ in their evaluations of care [8]. The sampling strategy attempted to maximise this variability by selecting individuals across the age range and by including male and female patients. The
Results
The results section is divided into three main sections. The first section reports on the utility of the concept of satisfaction. The second section presents the way in which patients described and evaluated their care, before focusing on how patients expressed their negative evaluations, using adaptive strategies. The final section describes the process of weighing up of evaluations and briefly considers some of the factors that influenced the way patients expressed their evaluations.
Discussion and conclusion
Exploring and measuring patient’s experiences is an integral part of health care evaluation [20]. Despite the importance placed on patient feedback, concerns about the conceptual and methodological integrity of current concepts and approaches have cast doubt on the results of studies of patient experience, particularly in relation to the concept of satisfaction [2], [16]. This study provides further evidence which questions the validity of satisfaction as providing an appropriate conceptual
Acknowledgements
The authors would like to thank all the patients who participated in this study and to the steering group, Dr. Lesley Duff, Dr. Jan Savage, Mark Avis and Dr. Tina Miller. This study was funded by a PPP Healthcare Medical Trust Millennium Fellowship Grant. There is no conflict of interest.
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