594196 review-article2015

RSH0010.1177/1757913915594196Conceptualisation of patient satisfaction: a systematic narrative literature reviewConceptualisation of patient satisfaction: a systematic narrative literature review

Peer Review Conceptualisation of patient satisfaction: a systematic narrative literature review

Conceptualisation of patient satisfaction: a systematic narrative literature review Authors Enkhjargal Batbaatar Department of Health Policy and Management, School of Public Health, Mongolian National University of Medical Sciences, S. Zorig street 3 Ulaanbaatar, 14210 Ulaanbaatar, Mongolia Faculty of Economy and Business Sciences (Facoltà di Scienze Economiche e Aziendali), University of Sannio, (Università degli Studi del Sannio), Via delle Puglie, n. 82, 82100 Benevento, Italy Email: [email protected] Javkhlanbayar Dorjdagva Department of Health Policy and Management, School of Public Health, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia The Institute of Public Health and Clinical Nutrition, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland Ariunbat Luvsannyam Department of Business Management, Ulaanbaatar University, Ulaanbaatar, Mongolia Pietro Amenta Faculty of Economy and Business Sciences, University of Sannio, Benevento, Italy Corresponding author: Enkhjargal Batbaatar, as above

Keywords patient satisfaction; customer satisfaction; satisfaction theory; conceptualisation; expectations; systematic review; RAMESES guideline; narrative literature review

Abstract Aim: Patient satisfaction concept is widely measured due to its appropriateness to health service; however, evidence suggests that it is a poorly developed concept. This article is a first part of a two-part series of research with a goal to review a current conceptual framework of patient satisfaction and to bring the concept for further operationalisation procedures. The current article aimed to review a theoretical framework that helps the next article to review determinants of patient satisfaction for designing a measurement system. Method: The study used a systematic review method, meta-narrative review, based on the RAMESES guideline with the phases of screening evidence, appraisal evidence, data extraction and synthesis. Patient satisfaction theoretical articles were searched on the two databases MEDLINE and CINAHL. Inclusion criteria were articles published between 1980 and 2014, and English language papers only. There were 36 articles selected for the synthesis. Results: Results showed that most of the patient satisfaction theories and formulations are based on marketing theories and defined as how well health service fulfils patient expectations. However, review demonstrated that a relationship between expectation and satisfaction is unclear and the concept expectation itself is not distinctly theorised as well. Conclusions: Researchers brought satisfaction theories from other fields to the current healthcare literature without much adaptation. Thus, there is a need to attempt to define the patient satisfaction concept from other perspectives or to learn how patients evaluate the care rather than struggling to describe it by consumerist theories.

Introduction Patient satisfaction has been a popular term in health service in the last few decades owing to its appropriateness.1–3 Evaluating patient satisfaction with health services allow some positive changes in the quality of healthcare delivery4 by identifying problems. A reflection of patients’ views in the functioning of a health service improves service management, and health professionals’ behaviours as determining proper policies and management procedures and prioritising resource allocations and training needs.2,5 A higher level of patient satisfaction results in patients’ decisions to choose a health service, to have an intention to return to a particular hospital, or to follow up doctor’s appointments or a recommended treatment option.4,6,7 National and international organisations for health service assessments set patient

satisfaction as one of the key indicators for controlling health service outcomes and reimbursing hospitals. Hereby, patient satisfaction is no longer only ‘the right thing to do’, it is the way to maintain market share.8 Furthermore, the service quality is cumbersome to measure; thus customer satisfaction is tremendously used to evaluate the quality due to its relative easiness.9–12 Literature evidence shows that patient satisfaction has been extensively studied since the 1960s; 13,14 however, the studies produced different puzzles and an incomplete whole picture of the comprehensive framework which guides the evaluation of patient satisfaction.15 Seemingly, patient satisfaction is a practical and politically important issue, albeit it is an undertheorised concept, but commonly measured.16 The terminology of patient satisfaction is

Copyright © Royal Society for Public Health 2015 Month 201X Vol XX No X l Perspectives in Public Health  1 SAGE Publications Downloaded from rsh.sagepub.com at University of New England on July 21, 2015 ISSN 1757-9139 DOI: 10.1177/1757913915594196

Peer Review Conceptualisation of patient satisfaction: a systematic narrative literature review ambiguous and divergent in the literature and is a complex concept under many affecting factors. While there is no globally accepted definition, the measurement systems vary across studies as well.7,15,17 Logically, theoretical development should be an antecedent of the measurement for any concept – unfortunately the inverse has been the case in service satisfaction research, including health services.15 There is a need for satisfaction and for researchers to put more effort into conceptualising patient satisfaction rather than testing inter-correlations of variables.18 This article is the first part of a two-part series of research with a goal to review a current conceptual framework of patient satisfaction for further operationalisation procedures. The current article aimed to review a theoretical framework that helps the next article to review determinants of patient satisfaction for designing a measurement system.

Methods We used a systematic review method, which is rooted in an earlier work of Thomas Kuhn. This was applied to the organisational research, a so-called meta-narrative review.19–22 This relatively new methodological approach allows us to combine a differently conceptualised topic from quantitative and qualitative evidence, by contradicting current research traditions with comprehensive and rigorous judgements. This ‘new’ approach has a time dimension and allows the reviewer to look back at how a particular research tradition or group has unfolded the topic over time, and what kind of methods were used. Furthermore, this new approach presents the results and what still needs to be achieved.20,22 Our goal was to identify studies that made significant contributions, either theoretically or empirically, to patient satisfaction theory. We started by searching seminal articles which were frequently cited and were considered to shape the development of patient satisfaction theory. This was completed by reference tracking to reach a consensus on the best-suited systematic

review method. Seminal papers of patient satisfaction theory resulting from the reference tracking were heterogeneous; there was a lack of complete and comparable statistical data and qualitative evidence from contradicting research traditions. Therefore, the nature of patient satisfaction data led us to employ a meta-narrative analysis. Therefore, we followed the RAMESES publication standards for meta-narrative reviews.22 Figure 1 shows methodological steps followed in the phases, which were modelled in earlier works20 and the RAMESES publication standards.22

Literature search Articles were searched in two databases, MEDLINE and CINAHL, due to their extensive collection of relevant articles according to our preliminary test on these databases including EMBASE and Cochrane. EMBASE and Cochrane were rejected on account of hundreds of irrelevant records generated. According to the keywords used in the previous systematic reviews with similar purposes, we adopted the keywords ‘patient satisfaction’ AND ‘concepts’, or ‘patient satisfaction’ AND ‘theory’, or ‘meaning’ AND ‘patient satisfaction’, or ‘patient satisfaction’ AND ‘conceptualisation’, or ‘exploring’ AND ‘patient satisfaction’, and applied them to the selected databases. Reference tracking was used to identify key articles which made main theoretical contributions to the understanding of patient satisfaction and those which were not found in the selected databases. These databases were reviewed from 15th June to 24th September 2014. Our search hit 5,916 records, with the following search limitations: articles published in full in peer-reviewed journals, between 1980 and 2014 for MEDLINE, and between 1983 and 2014 for CINAHL, and English language articles. We had 433 abstracts after removal of irrelevant, duplicated titles and abstracts.

Screening and appraisal Each abstract was systematically reviewed by relevance (with the theme as patient satisfaction conceptualisation),

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potential contribution to the concept and use of valid methods by two of our independent reviewers. For every abstract, the decision to include or exclude for the next phase was made on the basis of their consensus. If there was any disagreement, the reviewers would discuss the topic until they had reached a mutual agreement. All letters, comments and editorial papers were excluded. At this initial appraisal stage, our aim was to include as many articles as possible which met the basic methodological criteria or those which seemingly contributed to the concept, unless they were irrelevant or tragically flawed. We retained 58 articles for the next step of screening.

Final screening and data extraction We developed and applied a data extraction template to ensure each article’s relevance to study focus and scientific quality for further extraction. Moreover, the Critical Appraisal Skills Programme (CASP) checklist23 was tested for all 58 downloaded articles and reviewed by two reviewers independently to assess methodological quality of studies. Disagreements were reconciled by mutual agreement. Some 36 articles were selected for the next step of analysis which were deemed to meet the assessments of methodological quality. Inter-rater reliability using the Kappa statistic was 82.3%. Information from all 36 articles was extracted by study aim or research question, study design, setting, county, year, data collection method, sampling size, validity of method, study focus (development of theoretical framework or empirical analysis of concept), theoretical basis, quality criteria, significant findings, validity of conclusions and so on. The systematic review followed six guiding principles of the RAMESES guideline.22 In order to conceptualise patient satisfaction, finding an intersection point of formulations of patient satisfaction by different perspectives is important. Thus, patient satisfaction theory was unfolded over time including years of 1978–2012 by different perspectives such as service marketing, organisational behaviour,

Peer Review Conceptualisation of patient satisfaction: a systematic narrative literature review Figure 1

Search phase

Methodological steps Medline – 3,568 records

CINAHL – 1,811 records

Reference search – 537 records

Search results combined – 5,916

Synthesis

Appraisal

Screening phase

Excluded - 375 duplicated and - 5,108 irrelevant tles 433 arcles included aer screening on the basis of tle and duplicaon Excluded – 375 irrelevant abstracts 58 arcles assessed for quality criteria Excluded – 12 arcles unmet methodological quality criteria

36 arcles included in the synthesis

16 empirical studies

health service, psychology and so on in different research traditions. Emerging findings from each included study were reflected throughout the review. We used the quality assessment checklist (CASP) to avoid possible biases. Also, we attempted to make decisions on higher levels of agreement among reviewers to draw consistent conclusions.

Data analysis In the analytic process, we categorised the articles by research traditions and subject areas, followed with grouping articles by their philosophical bases and assumptions, and we identified the theoretical and conceptual models proposed by the recognised experts in each philosophical assumption. Then, we explored the historical development of proposed theories, methods and instruments in each philosophical assumption. Each philosophical

20 non-empirical studies

assumption was subdivided into parts, which created a broader and logical picture with contributions from different research traditions with different questions, methods, judgements, findings and interpretations.19,20 Our analytic method was similar to the interpretivist analysis principles by analysing the data through repetitive reading and analysis of quantitative data. In addition, our method explored how data and the findings from each article would fit into and affect the whole picture.22 In the synthesis process, we considered the commonalities and differences in underlying philosophical and theoretical assumptions of each study’s findings. We then examined how these different philosophical assumptions were involved in theorising, and whether contradiction of the theories or conceptualisations of patient satisfaction

related to their different underlying assumptions and research methodologies. Also, we explored the patterns that cause the contradicting understandings.

Results Formulations of patient satisfaction The word ‘satisfaction’ is found in dictionaries as a ‘fulfillment of one’s wishes, expectations, or needs, or the pleasure derived from this’, and additionally, it has a meaning that something is right, such as ‘the payment of a debt or fulfillment of an obligation or claim’.24 When satisfaction is applied to the patient with health service, it means a congruence of healthcare service and patient need, desire or expectation.25 In the health service literature, terms ‘consumer’, ‘customer’ and ‘patient’ are used interchangeably,8 although as dictionary definitions, these terms are

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Peer Review Conceptualisation of patient satisfaction: a systematic narrative literature review distinguishable. The Oxford Online dictionary defines these terms as follows: Consumer – a person who purchases goods and services for personal use. Customer – (1) a person who buys goods or services from a shop or business; (2) a person of a specified kind with whom one has to deal. Patient – (1) able to accept or tolerate delays, problems or suffering without becoming annoyed or anxious; (2) a person who is receiving or registered to receive medical treatment; (3) the semantic role of a noun phrase denoting something that is affected or acted upon by the action of a verb.26–28 Considering the above definitions, the terms ‘consumer’ and ‘customer’ might be explained synonymously as a user of any services or products. In fact, the term ‘patient’ is suitable in health service satisfaction due to its specific meaning as a user who is under an influence of professionals, informed, supported and treated for his or her own sake.8 Since the 1960s, there have been several attempts to formulate patient satisfaction from both marketing and healthcare fields. In 1970, Hulka and her associates formulated patient satisfaction as ‘… the patient’s attitudes toward physicians and medical care’.29 In 1982, Linder-Pelz defined patient satisfaction based on an attitude theory as ‘patient satisfaction is positive evaluations of distinct dimensions of the health care’.30 She argued that patient satisfaction is a positive attitude with an evaluative and affective nature, and individuals evaluate different aspects of healthcare based on a weighted sum of the beliefs to make an overall attitude.30–32 Pascoe6 defined patient satisfaction as ‘… a health care recipient’s reaction to salient aspects of the context, process and result of their service experience’. According to this description, patient satisfaction is a comparison of individual’s subjective standards to his or her health service experience. A comparison process involves cognitive evaluation and affective response of

structure, process and outcome of the service.6,31 Swan et al.33 defined patient satisfaction as ‘…an emotional response to the experience of hospitalization, but it is a cognitive process of comparing results to standards’. Similarly, Eriksen25 formulated that ‘…patient satisfaction is a rating of evaluation of a service or provider based on a comparison of the patient’s subjective standards to care received, and presents a positive emotional response to the comparison’. Hills and Kitchen34 described patient satisfaction as ‘…a sense of contentedness, achievement or fulfillment that results from meeting patients’ needs and expectations with respect to specific and general aspects of health care’. The above given definitions have three common characteristics regardless of the fields (marketing and health) the formulations were derived from. First, satisfaction is an emotional or affective 35,36 evaluation of the service based on cognitive processes which were shaped by expectations.29,35–37 Second, satisfaction is a congruence of expectations and actual experiences of a health service. Finally, it is an overall evaluation of different aspects of a health service.29 Indeed, patient satisfaction is a multidimensional,10,29,38–40 implicit and not systematically developed concept.16,37,39,41,42 It has different meanings for each individual according to beliefs, values, perceptions, emotions, personal characteristics, health condition12 and previous experiences with healthcare and the way to perceive the term ‘care’. Thus, it is a subjective,5,41–43 dynamic process as it is relative of a human judgement theory.16 There is no commonly accepted definition of satisfaction, and the operational definitions differ in the literature; however, this is possibly due to being measured in specific facilities, activities or episodes.29,41 Mpinga and Chastonay5 stated that patient satisfaction presents voices of patients about their health service experience; therefore, it is a proper indicator of human rights violations in the health sector. Furthermore, they concluded that politically, patient

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satisfaction is patient opinion as a democratic necessity; sociologically, it is an evolving issue with changing expectations of both patients and providers with respect to social, economic and technological development; and legally, patient satisfaction is a legal obligation expressed as an indicator of service quality.5

Patient satisfaction theories In the consumer satisfaction literature, satisfaction is commonly defined by a consumer subjective judgement of their expectation and the actual experience of the product/service.25 In the patient satisfaction literature, formulations are predominantly similar as depending on expectation as consumer satisfaction theory.8 Expectation theories are originally developed in psychology and borrowed by marketing research.6 Some researchers believe that expectation is the central importance of patient satisfaction,15,37,41 and that expectation theories simply explain patient satisfaction as a result of how well a health service fulfils patients’ expectations.8,18,34,36,37,39,43–45 The following are the theories attempting to explain patient satisfaction by a relationship of expectation, adopted from service literature.6

Value expectancy model.  Expectancy value theory was originally developed to explain and predict an individual’s attitudes towards actions. Later, Linder-Pelz created the value expectancy model based on the expectancy value theory by proposing five social–psychological variables, including expectations, as determinants of patient satisfaction.15,30,46 However, regarding this model, expectations explain merely 8% in variances of one aspect of satisfaction, physician conduct. Hence, the model failed to be supported.6,47 Furthermore, Pascoe stated that the expectancy value model has a problem with patient satisfaction conceptualisation because satisfaction is more affected by a reaction of prompt experience of healthcare rather than prior expectations and general values of patients.6

Peer Review Conceptualisation of patient satisfaction: a systematic narrative literature review Fulfilment theory.  A simple difference between patient’s expectations and experience is explained by the fulfilment theory.30,46 The bigger the gap between expectations and experiences, the greater the satisfaction or dissatisfaction.45,48 However, the fulfilment theory was rejected by Linder-Pelz;47 despite that, the theory suffers from logical and empirical weaknesses because according to the theory, the experience of the service alone explains satisfaction without considering psychological factors which are involved in the evaluation of the experience.6

Discrepancy theory.  Satisfaction is a perceived discrepancy between what patients expected and what they experienced as a proportion of those expectations.6,17 Therefore, expectation is the baseline of the discrepancy theory.6 The weakness of this theory is that when there is a deviation between expectations and experiences, it is explained as only dissatisfaction, regardless of whether it produces surprise or dissatisfaction.6 This theory also was tested by LinderPelz, and the result showed that satisfaction had an inverse relationship with discrepancy as ‘…the better the perceived occurrence in relation to prior expectation, the more satisfaction’.8,15,46,47 Disconfirmation theory.  A consumer compares his or her perceptions of a service to expectations and (dis)satisfaction as a consequence of the extent and direction of difference between perceptions and expectations.34,35 The higher the expectation, the less likely the performance is exceeded and the lower the satisfaction.48 On the other hand, if positive experiences confirm positive expectations or positive experiences disconfirm negative expectations, satisfaction occurs and vice versa.45 Hills and Kitchen34 concluded that disconfirmation paradigm is the most appropriate to explain an association between expectations and satisfaction on the basis of expectations. Equity theories.  Satisfaction exists when an individual accepts that a ratio of input

(how much money and time they spent and how much pain they had, etc.) and output of the service (how much better their health becomes) is fair. Moreover, equity theory relates to social comparison theory because an individual compares a value of the service he or she received to other individuals.30,33,35,46,48

Multiple models theory.  Contrary to the Linder-Pelz theory, Fitzpatrick proposed three independent models of patient satisfaction which consider that satisfaction cannot be a single concept but is formed by several determinants. The first model explains that expectations vary owing to the social dissimilarities, and so does satisfaction. The second model describes that achieving health goals with the help of healthcare is a major critique for some patients rather than satisfaction. The third model interprets that some health problems cause emotional uneasiness. Due to these emotional experiences, patients cannot be satisfied.15,49 Briefly, Fitzpatrick concluded that patients’ expectations are under the influences of their assumptions of possible health outcomes and the degree of violation of patients’ self-sense by their illness and healthcare services.17,49 He supported the models by examples of the United States and the United Kingdom; however, the literature reveals it to be inexplicit.15 Need theory.  Some researchers attempted to interpret patient satisfaction by Maslow’s human motivation theory. They assumed that the needs of patients are equal to patient expectations.31 Hills and Kitchen justified that the degree of patient satisfaction is the result of the fulfilment of Maslow’s hierarchy of needs. Self-actualisation is the highest order of needs, and once this need is fulfilled, the individual is likely to be satisfied with healthcare. In order to fulfil the last need of the hierarchy, all physical and psychological needs of a patient should be fulfilled. These needs may vary from individual to individual with respect to their personal characteristics, pathologies and healthcare settings, although health professionals should understand patients’ needs and react in accord-

ance.34,36 Johnson50 attempted to compare Maslow’s hierarchy of needs and the normative model to understand what optimises patient satisfaction and the quality of healthcare. According to the normative model, patient outcomes from health service are classified into four groups: disease eradication, patient performance, general health and patient satisfaction in ascending order of hierarchy. Johnson proposed that Maslow’s physiological needs, safety needs, esteem and love needs and self-actualisation needs are parallel to disease eradication outcome, patient performance outcome, general health outcome and patient satisfaction outcome of health service hierarchy, respectively. By the synthesis of two theories, Johnson50 expressed that the ultimate determinant of motivation, self-actualisation, is expected to be fulfilled once all other human needs are met in Maslow’s need hierarchy; similarly, patient satisfaction is an ultimate challenge to healthcare providers, and thus it is anticipated to be fulfilled only after all patient outcomes are met.

Attribution theory.  Basically, the attribution theory interprets how individuals understand the circumstances and what causes the behaviour of the understanding. Service providers and customers may have different causes to explain unmet expectations, and these conflicted causes lead to dissatisfaction. Therefore, the attribution theory plays a role in explaining the causes of mismatch of expectations and experiences.35 Economic theory.  Essentially, economic theory regards that customers seek services under a consideration of, at least, an equality of service quality and the price they pay for the service. This theory shares some common ground that expectations and customers are satisfied only if their expectations of service quality are equal to the price they paid.45 Study results concluded that acknowledging patient’s expectations at the beginning of the treatment directs to an effective service;41 however, some of the expectations are changed during the episode of care.18 Furthermore, expectations are situation specific,

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Peer Review Conceptualisation of patient satisfaction: a systematic narrative literature review influenced by past experiences, personal characteristics and environmental factors.8,51 Several types and levels of expectations (e.g. predicted, normative, unformed or partly formed, expectancy probability, process and outcome expectations, etc.) have been revealed in the earlier literature as a part of patient satisfaction conceptualisation attempts; nonetheless, their terminology usage and focuses were different.18,48 If expectations are used as a measurement of satisfaction, it is necessary to determine which type and level of expectation is compared by a patient.6,48 Furthermore, researchers should take into account an effect of assimilation and contrast,6,35,36,45 and zone of tolerance35,36 on patients’ subjective standards when they process satisfaction.6,31 The above patient satisfaction theories heavily count on a single concept of expectation and thus failed to be supported in healthcare service. Due to the drawbacks of expectationsbased approaches, there are other attempts to develop the patient satisfaction concept on the basis of health service components,45 started by Ware et al.13 by clarifying it is a multidimensional concept, under the influence of a number of internal and external aspects of health service.

Healthcare quality theory.  Donabedian argued that patient satisfaction is an outcome of interpersonal care, and it is a positive judgement about all aspects of quality of care, particularly about interpersonal care.17 Holistic approaches.  These approaches attempted to build a comprehensive framework to investigate interrelations of variables that have an impact on patients’ evaluations by encompassing all influences on satisfaction.45 The overall satisfaction is a collective feeling which is made up of positive or negative emotional responses of different factors of hospital service. These factors of services are usually adopted from the extant literature. Perhaps, the factors of service differ across the studies; however, results consistently confirmed that the patient

satisfaction concept is multidimensional.45

Discussion The evidence presented in this systematic review supports the findings of previous studies that patient satisfaction is a crucial, multidimensional and widely measured outcome of health service; however, the formulation varies due to its theoretical and conceptual immaturity. The theories, that attempted to explain patient satisfaction on the basis of expectations, are marketing-oriented and none of them are supported to explain patient satisfaction. Because they are not entirely applicable to the health service, consumer and patient satisfaction are not homogeneous concepts. Health service is multifaceted, a mixture of different aspects, and its use cannot be regarded as same as the consumer product concept.35 The evidence suggests that the nature of relationship between patient expectations and satisfaction is unclear,46 and there is no globally accepted knowledge that how and to what extent unmet expectations affect overall satisfaction.41 In addition, there is a weak or sometimes controversial link18,52 between patient expectations and satisfaction in the literature, and expectations explain a small amount of variations in satisfaction.46,48,49 Bowling et al.48 conducted a systematic review on the relationship between doctor pre-consultation expectations and satisfaction, and the results show that associations between expectation and satisfaction are inconsistent across the involved studies, except that a significant association exists only in primary healthcare. Literature indicates that there are few reasons for expectations to not be able to explain satisfaction fully. First, the nature of relationship between expectations and satisfaction is not well known, and they might not be related in a simply explainable way.18,46 Some studies demonstrate that a relationship exists, whereas others contradict this theory. Some expectations are found to be unstable or changeable

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in the studies, some are positive or negative and some are expressed with a value. Therefore, the researchers inferred that expectations can be modified by the situations or process of services or mitigated over time due to the constraints of the service.18,31,52,53 Fitzpatrick and Hopkins49 stated that patients judge doctors’ consultations by balancing criticism of the service and respect for other patients’ conditions, understanding how negative occasions of service are unavoidable, and perceiving health service quality with sympathy. Similarly, in a later study, Williams et al.53 concluded that patients’ expectations might be shaped by the appraisal of what rights patients have in the health service and what duties health services have. Thus, patients do not expect more than service duties and respect others’ rights. Therefore, every negative experience of health service does not necessarily produce negative evaluations. This assumption reduces the importance of expectations in satisfaction and causes some expectations to be inappropriate.53 Expectations may not be directly related to satisfaction; however, there possibly can be an indirect association between expectations and satisfaction. On the other hand, patients may use different decision models for expectations regarding their health service knowledge.44 Expectations can differ among the population according to knowledge and prior experiences. Moreover, socioeconomic status, values and attitudes may play a confounding role for expectation levels.15 Some evidence shows that pathology of the patients’ conditions influences their expectations.34 Also, studies conclude that there exist different types of expectations;18,52 nevertheless, there is no strong evidence of the relationship between expectancy type and patient satisfaction.48 Apparently, a single link between expectation and satisfaction cannot explain patient satisfaction entirely, unless other factors of patients such as cultural norms, demographics, socioeconomic variables,45 attitudes, beliefs and perceptions are considered to make an evaluative judgement.34

Peer Review Conceptualisation of patient satisfaction: a systematic narrative literature review Second, in the studies, expectations are mostly expressed in an implicit and tentative way,31,49 from which expectations should be distinguished whether they are based on previous experiences or desires/needs.31 Furthermore, in practice, it is complicated to measure either expectations or experiences; particularly, expectations can be easily manipulated by service personnel or information.45 Third, we do not fully understand the exact way in which patients develop expectations and the way they express it; thus, we may not be able to explain what really patients anticipate from the service and what they really want to tell. These misleading results probably come with the methods we used to conduct the survey,31 or there are no expectations existing with the health service in reality due to the patients’ passive role in health service.31,46 Finally, expectation is a multidimensional and dynamic concept which is developed over time by patients under the influence of personal, socio-demographic characteristics, their belief system,

previous experiences and pretreatment conditions. Like satisfaction, expectation is an ambiguous, conceptually and methodologically under-theorised concept. Consequently, it is risky to explain satisfaction by using the uncertain and inexplicit term, expectation.48

Limitations The most obvious limitation of this study was restricting sources to two online databases and not including sources such as book chapters and grey literature in searching phases due to the constraint of time and budget. Another limitation of this study was the quality of the studies involved. The majority of the evidence was from qualitative design studies and was outof-date. Moreover, theoretical evidence was deficient in empirical supports.

Conclusions Researchers since the 1960s have formulated the theory of patient satisfaction on the ground of expectations as the same as

consumer satisfaction theories, and later researchers have been bringing these formulations to current literature without much effort and change. Patient satisfaction is not clearly defined because it possibly still is explained by a consumerist approach which misleads the definition in health service. There is no solid evidence that expectation is an antecedent of satisfaction or closely related to satisfaction. Therefore, the review suggests that we should make an effort to define the patient satisfaction concept from the other perspectives or to learn how patients evaluate the care they received.

ACKNOWLEDGEMENTS This research received a grant from the Sustainable E-Tourism Programme, Erasmus Mundus Action 2 – Strand 1 with a grant agreement number 20102359/001-001-EMA2.

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Conceptualisation of patient satisfaction: a systematic narrative literature review.

Patient satisfaction concept is widely measured due to its appropriateness to health service; however, evidence suggests that it is a poorly developed...
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