Patients evaluations of their health care: the expression of negative evaluation and the role of adaptive strategies

https://doi.org/10.1016/j.pec.2003.09.002Get rights and content

Abstract

Patient experiences surveys have become common within healthcare and represent an important form of participation, with patients having the potential ability to influence the quality of care. However, there is still a relatively limited understanding of how patients evaluate the quality of their care. We present the findings of a qualitative study, which explored the way in which patients express their evaluations, in an attempt to move the debate forward. The results indicate that patient evaluation appears to be far more complex than routinely acknowledged, particularly in relation to the expression of negative experiences. Patients were reluctant to offer directly negative criticisms, needed particular conditions in which to express their negative evaluations and used a variety of adaptive strategies to overcome social pressures that inhibited negative evaluation and promoted positive evaluation. We argue that standardised approaches to measuring negative evaluations, such as questionnaires, need to become more sensitive to the complexities of negative evaluation. This would enhance the extent to which patients can participate in influencing the quality of care. A number of recommendations are made to develop the sensitivity of future investigations into the negative aspects of patient experiences.

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.

References (23)

  • S. Linder-Pelz

    Towards a theory of patient satisfaction

    Soc. Sci. Med

    (1982)
  • S. Linder-Pelz

    Social psychological determinants of patient satisfaction: a test of five hypotheses

    Soc. Sci. Med

    (1982)
  • G. Pascoe

    Patient satisfaction in primary care: a literature review and analysis

    Eval. Prog. Plann

    (1983)
  • P. Cleary

    The increasing importance of patient surveys

    Br. Med. J

    (1999)
  • C. Edwards et al.

    Accessing the patient’s perspective

    Health Soc. Care. Comm

    (2000)
  • J. Coyle

    Exploring the meaning of ‘dissatisfaction’ with health care: the importance of ‘personal identity threat.’

    Soc Health Illness

    (1999)
  • S. Staniszewska et al.

    The concepts of expectations and satisfaction—do they capture the way patient’s evaluate their care

    J Adv Nurs

    (1999)
  • Mulcahy L, Tritter JQ, Pathways, pyramids and icebergs. Mapping the links between dissatisfaction and complaints. Soc...
  • B. Williams

    Patient satisfaction: a valid concept?

    Soc. Sci. Med

    (1944)
  • R. Carr-Hill

    The measurement of patient satisfaction

    J. Pub. Health Med

    (1992)
  • Fitzpatrick R. Scope and measurement of patient satisfaction. In: Fitzpatrick R, Hopkins A, editors. Measurement of...
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