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Patient satisfaction with nursing care as an outcome variable: Dilemmas for nursing evaluation researchers
Patient Satisfaction With Nursing Care As an Outcome Variable: Dilemmas for Nursing Evaluation Researchers CHIA-CHINLIN, PHD, RN*
Evaluation is one of the most critical phases of the nursing process because it supports the basis of the usefulness and effectiveness of nursing practice. Nursing practice is patient driven and patient centered. Accordingly, patient satisfaction has been strongly advocated by nursing professionals to be an important indicator of quality of nursing care delivery. This article discusses the conceptualization and measurement of patient satisfaction with nursing care. Also, this article examines numerous dilemmas related to conceptualization and methodology that nursing evaluation researchers confront when attempting to use patient satisfaction as an outcome variable. Based on the current knowledge regarding the nature of patient satisfaction, implications for future nursing evaluation research are proposed and discussed to overcome these dilemmas in measuring patient satisfaction as an indicator of quality of nursing care. (Index words: Evaluation research; Patient satisfaction; Quality assurance; Quality of care) J Prof Nurs
12:207-216, 1996. Copyright© 1996 by W.B. Saunders Company
VALUATION is one of the most critical phases of the nursing process. Evaluations serve at least the following three functions: determine the effectiveness of a program, assess the utility of a new program, and satisfy the accountability requirements of program sponsors (Rossi & Freeman, 1993). Therefore, to improve the quality of nursing care, evaluation is especially crucial because it supports the basis of the usefulness and effectiveness of nursing practice. As suggested by Donabedian (1980), "The degree of quality is the extent to which the care provided is expected to achieve the most favorable balance of risks and benefits" (p. 5). Donabedian divides quality of care into two domains: the technical and the interpersonal. Technical care (science of care) is the application of any science or technology of medicine to manage a
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*AssociateProfessor, School of Nursing, Taipei Medical College,Taiwan,ROC. Addresscorrespondenceand reprint requeststo Dr Lin: School of Nursing, Taipei Medical College, 250 Wu-Hsing St, Taipei, Taiwan, ROC. Copyright© 1996byW.B. SaundersCompany
8755-7223/96/1204-0007503.00/0
health problem; on the other hand, interpersonal care (art of care) refers to the management of the social and psychological interaction between client and practitioner. Donabedian also proposes a third element in the quality of care, which is called amenities, such as a pleasant and restful waiting room. However, he later considers this as part of interpersonal care. Donabedian's (1980) structure, process, and outcome framework provides a useful means for evaluating the quality of nursing care. He identifies three approaches in the evaluation of quality of care: structure, process, and outcome. First, structure of care is defined as "the relatively stable characteristics of the providers of care, of the tools and resources they have at their disposal, and of the physical and organizational settings in which they work" (p. 81). Structure of care includes resources such as the human resources, physical equipment, and finances that are needed to provide care. Second, Donabedian (1980) defines process of care as "a set of activities that goes on within and between practitioners and patients" (p. 79). Process can also be defined as normative behavior, which derives from the science of medicine or from the ethics and values of society (Donabedian). Process in quality of nursing care could be the activities of nurses in demonstrating their knowledge to patients and the degree to which nurses conform to their expectations and those of patients. The third approach is to evaluate the outcomes of quality of care. Outcome of quality is referred to as "a change in a patient's current and future health status and improvement of social and psychological function that can be attributed to antecedent health care" (Donabedian, 1980, p. 82). Donabedian suggests that the outcome approach to quality assessment can provide an integrative and inclusive measure of the quality of the program because many factors that contribute to the quality are reflected by the outcome approach. He further summarizes several functions of outcome measures. First of all, outcomes provide indirect measures of process of care because process is much more difficult to measure. Outcomes also
Journal of ProfessionaINursing, Vol 12, No 4 (July-August), 1996: pp 207-216
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provide a link between process and outcome in the monitoring method to determine if the monitoring system is measuring what it is supposed to measure. Last, outcome measures function to screen clients who require further assessment from those who do not. Nursing practice is patient driven and patient centered. Accordingly, patients' perceptions of quality of nursing care can contribute to the evaluation of quality of nursing care by determining the values that are to be placed on nursing care. The patient's perception of quality of nursing care is regarded as patient satisfaction, which has been strongly advocated by nursing professionals to be an important indicator of quality of nursing care delivery (McDaniel & Nash, 1990) and an important outcome measure of evaluation of nursing care.
• . . assessment of patient satisfaction has become progressively more
interesting to a number of researchers...
Purposes of Assessing Patient Satisfaction in Nursing and Other Disciplines In recent years, the assessment of patient satisfaction has become progressively more interesting to a number of researchers in evaluating the quality of nursing care. Reasons for assessing patient satisfaction with nursing care have been based on the following rationales. First, assessing patient satisfaction provides a means of monitoring quality of nursing care and evaluating effectiveness of nursing interventions (Cottrell & Grubbs, 1994; La Monica, Oberst, Madea, & Wolf, 1986). Patient satisfaction also has been described as an indicator of patient outcome (Megivern, Halm, & Hones, 1992). Moreover, because patient participation is a central tenet of nursing care, seeking patients' opinions is considered to be a therapeutic nursing activity (Bond & Thomas, 1992). In addition, market forces have prompted hospital facilities to focus on promoting patient satisfaction (Scarding, 1994). Last, satisfaction with nursing care is the most important predictor of overall satisfaction with hospital care (Abramowitz, Cote, & Berry, 1987; Greeneich, 1993). Other purposes and rationales of measuring patient satisfaction have also been proposed in other disci-
plines, such as medicine. Those purposes and rationales are that patients with high satisfaction with care or service are more likely to comply with medical regimens (Wartman, 1983), are more likely to participate in their treatment (Bartlett, Grayson, Barker, & Levine, 1984), and are more likely to return and continue to use the medical services (Ware, Wright, & Snyder, 1975). In addition to the focuses of patient compliance and competition among medical services, Donabedian (1980) also points out that patient satisfaction provides feedback for the quality assessment process and program evaluation.
Conceptualization of Patient Satisfaction With Nursing Care Similar to other disciplines, patient satisfaction has been conceptualized inconsistently across studies in nursing. Early in 1975, Risser first proposed a definition of patient satisfaction with nursing care, which was described as "the degree of congruency between a patient's expectations of ideal nursing care and his perception of the real nursing care he receives" (p. 46). This definition was later adopted by some other researchers (eg, Cottrell & Grubbs, 1994; Hinshaw & Atwood, 1981; La Monica et al., 1986; Scarding, 1994). A similar definition (Greeneich, Long, & Miller, 1992) is that patient satisfaction is expressed as the match between patient expectations of nursing care and the care actually received. Marram, Flynn, Abaravich, & Carey (1976) defined patient satisfaction as patients' satisfaction with their nursing care and the degree to which they believed it was individualized and personalized. Additionally, Petersen (1988) provided a more general definition and explained patient satisfaction as "patients' perceptions of how their care was provided, excluding the outcome of their health status or the appropriateness of their therapy" (p. 26). Also, several researchers (eg, Lewis & Woodside, 1992; Munro, Jacobsen, & Brooten, 1994; Richard & Lambert, 1987) have left the definition of patient satisfaction to be interpreted by the reader. Researchers, then, have incongruently conceptualized dimensions of patient satisfaction with nursing care. Risser (1975) conceptualized patient satisfaction with nursing care as having three dimensions when she developed an instrument measuring this concept: (1) technical-professional behaviors, eg, technical activities and the knowledge base required to competently complete the nursing care tasks; (2) a trusting relationship, eg, nursing characteristics that allow for constructive and comfortable patient-nurse interac-
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tion and communication aspects of the interaction; and (3) an educational relationship, eg, nurses' ability to provide information for patients, including answering questions, explaining care, and demonstrating techniques. This conceptualization of dimensions has been employed by some other researchers (Bader, 1988; Hinshaw & Atwood, 1981). Another conceptualization of factors related to patient satisfaction, derived from Risser's conceptual framework, was suggested by other investigators (La Monica et al., 1986; Munro, Jacobsen, & Brooten, 1994) to indude dissatisfaction, interpersonal support, and good impression. Moreover, Greeneich, Long, and Miller (1992) conducted a review of patient satisfaction instruments and proposed a nursing taxonomy of patient satisfaction, which includes the following three dimensions: (1) the nurse's inherent personality characteristics, nursing care characteristics, and nursing proficiency; (2) the patient's expectations; and (3) the organizational environment, ie, nursing milieu. Still others (Megivern et al., 1992; Petersen, 1988) adopted a conceptual framework originating in the medical discipline (Ware, Davies-Avery, & Stewart, 1978) and describing patient satisfaction with nursing care as involving the following dimensions: art of care, accessibility and convenience, finances, physical environment, availability, continuity of care, and efficacy and outcomes of care. Adopting a marketing service perspective (Zeithaml, Parasuraman, & Berry, 1990), Scarding (1994) suggested that patient satisfaction with nursing care included five dimensions: (1) tangible, eg, the appearance of physical facilities, equipment, personnel, and communication materials; (2) reliability, eg, the ability to perform the promised service dependably and accurately; (3) responsiveness, eg, the willingness to help customers and to provide prompt service; (4) assurance, eg, the knowledge and courtesy of employers and their ability to convey trust and confidence; and (5) empathy, eg, the provision of caring, individualized attention to customers. Finally, some researchers (Lewis & Woodside, 1993; Richard & Lambert, 1987) have left the dimensions of patient satisfaction undefined. It is apparent that the construct of patient satisfaction is not consistently and clearly conceptualized. Most of the constructs of patient satisfaction have neither been replicated in other research nor well supported. Also, no researchers have specified the mechanisms by which patient satisfaction develops. Moreover, none of the constructs have discussed the nature (eg, a behavior or a belief/attitude) and the stability (change over time or stable) of patient
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satisfaction. Last, no directional hypotheses for testing patient satisfaction have yet been developed and tested. Instruments for Measuring Patient Satisfaction With Nursing Care
Most of the patient satisfaction instruments available to nursing are ordinal scales and are measured by rating on a Likert or Likert-type scale. One instrument rates satisfaction on a three-point scale ranging from "very satisfactory" to "not satisfactory" (Lewis & Woodside, 1992). Some instruments use a five-point scale ranging from "strongly agree" to "strongly disagree" (Hinshaw & Atwood, 1981; Munro, Jacobsen, & Brooten, 1994; Risser, 1975) or ranging from "poor" to "excellent" (Megivern et al., 1992). Some tools use a seven-point scale (from "strongly agree" to "strongly disagree" or from "very dissatisfied" to "very satisfied") (Cottrell & Grubbs, 1994; La Monica et al., 1986; Scarding, 1994). Only a few instruments have reported reliability and validity; however, many of them have not (Lewis & Woodside, 1992; Megivern et al., 1992). Risser (1975) developed the first standardized patient satisfaction measurement specific to nursing care. The 25-item Patient Satisfaction Scale (PSC) was originally developed to test four dimensions: technicalprofessional behavior, interpersonal-interpersonal relationship, trusting relationship, and educational relationship. However, in a later modification the intrapersonal-interpersonal relationship dimension was dropped without further explanation. This instrument was tested on 138 patients in primary health care settings. The reliability of the PSC was established by using Cronbach's alpha, which ranged from .63 to .91. Only the content validity was mentioned. No other types of validity were tested. The Patient Satisfaction Instrument (PSI) (Hinshaw & Arwood, 1981) was developed by revising one item on the PSC in order for it to be used with inpatient hospital patients. In the item, "The nurse gives good advice over the telephone," the phrase "over the telephone" was deleted. The PSI was tested in five studies with a total of 600 patients, primarily medical surgical inpatients and outpatients. Scores of patient satisfaction were highly positively skewed. The reliability estimated by internal consistency (Cronbach's alpha) ranged from .44 to .98. Several approaches were undertaken to estimate the validity. Multitrait monomethod was used to estimate the convergent and divergent validity by correlating the
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three constructs in the instrument (education, trusting, and technical-professional) with other different constructs (patient physical condition, direct care quality-nurse, and direct care-patient). It was found that the convergent validity coefficients were generally higher than the divergent validity coefficients. It then was concluded that this result provided an estimate of moderate to strong construct validation for the PSI. However, the measurements for heterotrait constructs (eg, patient physical condition) were not specified. Also, one of the reliability coefficients (direct care quality-patient) was lower than the convergent validity coefficient. Furthermore, the discriminate validity was estimated in three studies by examining the differences of patient satisfaction in three phases. The predicted differences were not found in one study. Intercorrelations among the three constructs (education, trusting, and technical-professional) were performed to assess the consistency within the instrument. It was found that the subscale-subscale correlation coefficients ranged from .28 to .90. In a 21 correlation matrix, seven of the coefficients exceeded .70, which means that there is considerable conceptual overlapping between the two constructs, especially between the technical-professional construct and the trusting construct.
. . . it is not appropriate to base validity on a significant t e s t . . .
The La Monica-Oberst Patient Satisfaction Scale (LOPSS) was originally developed to assess three dimensions of patient satisfaction based on Risser's conceptualization. However, the confirmatory factor analysis did not support this conceptualization, and the exploratory factor analysis generated other three factors: dissatisfaction, interpersonal support, and good impression. This instrument was tested on a total of 633 hospitalized oncology patients, and scores on the scale were highly positively skewed. Internal consistency ranged from .92 to .95. Construct validity was estimated by correlating patient satisfaction scores with mood scores (anxiety, depression, and hostility) measured by the Multiple Affect Adjective Check List (MAACL). Correlations between these two constructs were essentially low (-.20, -.21, and -.27). The authors claimed that although these correlations were not high, all were significant. Nevertheless, it is not appropriate to base validity on a significant test
because a significant correlation indicates only that the correlation is different from zero instead of high enough to establish validity. Additionally, the construct validity of the MAACL has not been well established and documented. Thus, the MAACL should not be used to test the validity of another construct because it is not appropriate to correlate two instruments, neither of which has established validity data (Allen & Yen, 1979). Last, the authors named this form of validity "discriminate validity," which seems to be a mistake. Munro, Jacobsen, and Brooten (1994) then reexamined the psychometric properties of the LOPSS on a total sample of 307 patients who had various conditions. Again, scores were highly positively skewed. Factor analysis generated only two factors: interpersonal support and dissatisfaction. Reliability (Cronbach's alpha) was .97 for the total instrument. Subscale internal consistency was not reported. The convergent validity was estimated by correlating the total score with the score on a single item that measured overall satisfaction and was found to be .32 to .46, an acceptable level. Nonetheless, this form of convergent validity provides only very weak evidence for validity. Cottrell and Grubbs (1994) modified the Risser Patient Satisfaction Instrument (1975) to adjust the nursing practice of a postpartum unit. Items were placed into four dimensions: communication, teaching, professional behaviors, and nurses' skills. Another revision was made to use a seven-point Likert-type scale instead of a five-point scale. Cronbach's alpha coefficients ranged from .80 to .97. Only content validity was established. Also, the subscale-subscale correlation coefficients were not reported. Scores on the scale were positively skewed. Scarding (1994) adopted the SERVQUAL from a marketing perspective. This instrument measures five dimensions: tangibles, reliability, responsiveness, assurance, and empathy. This measure was tested on a convenience sample of 10 postoperative cardiothoratic patients. Reliability was established by internal consistency ranging from .40 to .98. Only face validity and content validity were mentioned. Because of the extremely small sample size, the interpretation of reliability and validity becomes meaningless. The review of the existing instruments of patient satisfaction used in nursing shows that reliability and validity have posed a number of problems, which may be related to conceptualization. Reliability has been estimated only by internal consistency (Cronbach's alpha). No test-retest reliability has yet been estimated. The lack of an appropriate theoretical frame-
PATIENT SATISFACTION AS AN OUTCOME VARIABLE
work introduces difficulties in testing validity. As a result, in some instruments only face and content validity were mentioned. Most of the researchers failed to provide strong evidence for validity.
Factors Influencing Patient Satisfaction
Rubin (1990) suggests that several factors could influence patients' judgments of their satisfaction, including timing of survey, response format, and nonrespondence. Some other factors, such as demographic variables, expectations, general health status, and care delivered, have also been found in the literature to be related to patient satisfaction. TIMING OF SURVEY
Researchers have found that patients who were assessed at different points during their hospital stay or after discharge responded differently on measures of patient satisfaction. They found that patients surveyed during their stay or several months after discharge expressed greater satisfaction than did patients who had been discharged a few weeks before the survey was conducted (Ley, Kinsey, & Atherton, 1976). RESPONSE FORMAT
Rubin (1990) reports that no comparisons have been made among different response formats in eliciting patient ratings of satisfaction. Nevertheless, he suggests the potential advantages of using an "excellent-poor" scale over using an "agree-disagree" scale. For example, Ware and Hays (1988) found that "excellent-poor" scales with a neutral item stem elicited greater variance, were less skewed, and were more highly related to patients' behavioral intentions concerning health care than were direct scales of "very satisfied-not at all satisfied." NONRESPONDENCE
To date, there has been little research addressing whether a difference of patient satisfaction ratings exists between respondents and nonrespondents. However, it has been maintained that nonrespondents may be less satisfied with care than respondents (Ley, Kinsey, & Atherton, 1976). On the other hand, some researchers (Ware, Snyder, Wright, & Allison, 1983) found that patients who were more satisfied with their received care were less likely to return questionnaires.
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DEMOGRAPHIC VARIABLES
Demographic characteristics, such as age, gender, education, and race, appear to affect patients' ratings of satisfaction. These factors, however, have been reported to relate with patient satisfaction inconsistently. For example, Ware et al. (1978) concluded that relationships existed between many sociodemographic characteristics and satisfaction with dimensions of care. In contrast, Fox and Storms (1981) asserted that these demographic variables were characterized as chaotic and not having consistent relationships. It was reported that older patients were more likely to rate higher satisfaction (Pascoe, 1983); however, other researchers did not support this finding (Bader, 1988; Clear~ Kero)~ Karpanos, & McMullen, 1983). Furthermore, women were found to be more likely to be satisfied with care than were men (Pandiani, Kessler, Gordon, & Domkot, 1982); on the other hand, other researchers (Bader, 1988; DiStefano, Pryer, & Garrison, 1980) did not find any relationship between gender and satisfaction. EXPECTATIONS
Commonly, it is believed that satisfaction is related to expectations. Studies that explored the relationship between patient expectations and satisfaction showed that patients with lower expectations and restricted knowledge of services available are more likely to be more satisfied, whereas, those with higher or unrealistic expectations are less likely to be satisfied (Swan, 1985). GENERAL HEALTH STATUS
Health status is often thought to affect patients' ratings of satisfaction. Several studies have shown that a positive relationship exists between satisfaction and general health (Tompson, 1990). Cleary et al. (1983) found that perceived health was a strong predictor of overall satisfaction. On the other hand, some studies showed no relationship between health status and satisfaction (Fox & Storms, 1981). CARE RECEIVED
Recently, patient satisfaction has been used to evaluate health care as well as nursing practice. Although little research indicates that patients' satisfaction is related to perceptions of the provider's competence and technical skills (Meterko, Nelson, & Rubin, 1990), Ware, Wright, and Snyder (1975) found that patients were not able to evaluate providers' technical
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skills. For example, Ward and Gordon (1994) found that there was very little association between pain severity experienced by patients and patients' satisfaction with pain management, which means that these patients were satisfied with the pain management provided by their clinicians while they were concurrently suffering from moderate to extreme pain. It has been asserted that in general patient satisfaction is related to perceived interpersonal and communication skills (Cleary & McNeil, 1988). As a result, interpersonal and communication skills are the most frequently emphasized variables related to patient satisfaction. Several studies have supported this assertion. Patient satisfaction has been consistently found to be positively related to interpersonal skills, such as being caring and sensitive (eg, Passkey, 1985), and communicating clearly. Providing dear communication has been found to be one of the most important elements of overall satisfaction (eg, Cleary & McNeil,
1988). Bader (1988) conducted a survey that explored which nursing care behaviors predict patient satisfaction. Patients identified 15 nursing behaviors related to their satisfaction with nursing care. It was found that 12 of these were affective activities, such as being attentive, being friendly, and providing clear explanation. Only three of the behaviors were professional or technical activities, such as being skillful. Cottrell and Grubbs (1994) compared patient satisfaction with two types of postpartum nursing care: traditional nursing with rooming-in versus couplet nursing care. They found that patient satisfaction scores were highly positively skewed in both groups. Patients in both groups were highly satisfied with nursing care, with no difference in satisfaction between groups. The studies reviewed in this section provide evidence that patient satisfaction is more likely to be predicted by non-care-related factors, such as demographic variables, timing of survey, and expectations. However, variability and inconsistency characterize the results. Among the care-related variables, factors related to interpersonal care, such as interpersonal and communication skills, were much more strongly predictive of patient satisfaction than were technical care. This conclusion supports Donabedian's (1987) argument that patients are the paramount consideration in defining the quality of the interpersonal processes and of the amenities of care, but it does not consider patients' ability to judge the quality of technical areas of care. However, in general the studies reviewed have been characterized by a lack of conceptual clarity in
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both predictor and outcome variables with consequent diversity of findings. There is also no consistency in the way in which patient satisfaction is measured.
Problems in Using Patient Satisfaction As an Outcome Variable
Despite the increasing interest in evaluation among researchers who measure patient satisfaction, those who suspect the value of including patient satisfaction measures as indicators of quality of care have pointed to a number of factors that potentially limit the validity of this approach and have explained the reluctance to include patient satisfaction among quality of care criteria. Vouri (1987) summarized several problems caused by including patient satisfaction in quality assurance. Patients lack the scientific and technical knowledge necessary to adequately assess quality of care. Patients may be in physical or mental states that make them incapable of passing objective judgments. The rapid pace of events--nursing interventions, diagnostic tests, therapeutic measures--makes it difficult for patients to have a comprehensive and objective view of what is going on. Care providers and patients may have different goals for care; patients' wishes may be harmful or not in their best interest from the care provider's perspective. Patient satisfaction cannot be measured in a way that would yield useful results because it is difficult--if not impossible--to define what "quality" means to patients. The concept is dependent on many different patient characteristics, varying with age, sex, education, and socioeconomic status, varying between the stages of being critically ill to being well on the way to recovery. M1 of these variables bring the empirical validity of assessing patient satisfaction into question (p. 106). METHODOLOGICAL DILEMMAS IN MEASURING PATIENT SATISFACTION
Lack of a Consistent Conceptualization and an Appropriate Theoretical Framework
To date, there is no consensus about the definition and conceptualization of patient satisfaction. It has been pointed out that very little satisfaction research is theory-testing or theory-building (Aharony & Strasser, 1993). A lack of attention has been given to the conceptualization of patient satisfaction. Most researchers, thus far, are predominately interested in identifying sociodemographic factors rather than developing a theory. Without a consistent conceptualization and an accepted theory, the concept of patient satisfaction can
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not be adequately measured; thus, knowledge generation in this area is difficult. Also, research questions or hypotheses can not be justified or driven without a sound theol-F Furthermore, there is no consensus regarding which conceptual facets the concept of patient satisfaction encompasses (Bond & Thomas, 1992). Finally, no theorists have hypothesized and predicted the mechanism for forming patient satisfaction judgment and subsequent reaction (Aharony & Strasser, ! 993). Lack of a Reliable and Valid Approach to Measure Patient Satisfaction
The issue of reliability and validity of measures of patient satisfaction has posed a number of conceptual and operational problems for evaluation researchers across all disciplines, including nursing. Researchers have failed to provide adequate evidence for the reliability and validity of patient satisfaction measures. Most researchers have tested only internal consistency, whereas test-retest reliability has rarely been reported. Also, a number of researchers do not provide information regarding the reliability of their instruments.
A lack of attention has been given to the conceptualization of patient satisfaction.
Testing validity of patient satisfaction measures is a challenging task for researchers because of a lack of clarity in conceptualization and a lack of an appropriate theory. As Thompson (1986) has pointed out, patient satisfaction measurement generally lacks methodological as well as conceptual soundness, which makes examining validity of instruments perplexing. The review shows that several investigators failed to examine validity; however, some investigators attempted to establish validity by using a weak design. For example, some researchers tested validity by comparing a total patient satisfaction score with a single item score. The convergent validity alone indicates only very weak validity. Similar to testing divergent validity alone, some researchers reported only the correlation between the patient satisfaction construct and a different construct. Moreover, several investigators intended to establish construct validity by comparing patient satisfaction with another construct; unfortunately, neither of these constructs has established validity.
Because the ways of validating patient satisfaction measurement are not satisfying researchers, some researchers have made multiple efforts to overcome this problem and have provided suggestions. However, these solutions have limited potential success because of the constraint of a lack of theoretical framework. For example, Bond and Thomas (1992) recommend that researchers establish validity by comparing patient satisfaction with other variables, such as health care outcomes, compliance, and intention to return. Unfortunately, none of these variables has existing established valid measurement. Moreover, these constructs appear to be conceptually and logically distinct from patient satisfaction. Finally, the author has no justification for using intention to return as an criterion because patients tend to resist change. Once patients are more familiar with the hospital facility and the care, they are very unlikely to change the care unless they are highly dissatisfied. Insensitivity of Patient Satisfaction Measurements
The majority of existing tools have been found to be insensitive to discriminating patient satisfaction; namely, they generate highly positively skewed scores (Cottrell & Grubbs, 1994; La Monica et al., 1986; Scarding, 1994). No matter how good or bad the nursing care is, patients are generally highly satisfied. This bias is believed to be related to social desirability; which means that patients wish to please staff and fear repercussions for negative care appraisal (Pearson, Durand, & Punton, 1989). Therefore, different formats of measurement or different modes of administration may be needed to increase the sensitivity of patient satisfaction instruments.
Implications for Nursing Elevation Research Emphasis on patient satisfaction with nursing care as an indicator of quality of nursing care is increasing as evidenced by the greater frequency of empirical publications on the topic and the widespread use of measures of patient satisfaction by nursing evaluators. However, nursing evaluation researchers are confronted by a number of perplexing problems, such as a lack of consensus on the role of patient satisfaction in evaluating the quality of nursing care and numerous methodological dilemmas. If nursing evaluation researchers continue to consider patient satisfaction as
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an indicator of quality of nursing care, research efforts are needed to overcome a number of barriers that can potentially limit the validity of this approach. First, rigorous research needs to be undertaken to develop a theoretical framework of patient satisfaction that clearly defines the concept of patient satisfaction, specifies the conceptual facets patient satisfaction encompasses, and describes mechanisms for forming patient satisfaction judgements and subsequent reactions. With an appropriate theory, hypotheses and research questions can be driven and tested, and instrument validity can be rigorously established. Second, a reliable and valid tool for measuring patient satisfaction must be developed. Adequate evidence has to be provided to establish the reliability and validity of measures. Without a reliable and valid tool, the concept of patient satisfaction becomes unmeasurable, and information provided is meaningless. The test of validity of patient satisfaction measurement has been constrained by a lack of an appropriate theoretical framework. One possible solution proposed by the author to overcome this limitation is the use of the multitrait-multimethod process, which can provide strong evidence of construct validity. The multitrait-multimethod process was first developed by Campbell and Fiske (1956) and designed to judge the adequacy of a test as a measure of a construct. The basic idea of multitrait-multimethod validity is that a construct should be related to certain traits and unrelated to other traits. The researcher specified a priori a list of multiple ways to measure the construct and some distinctly different constructs that can be measured by the same methods. Convergent validity coefficients are correlations between measures of the same construct using different methods. Divergent validity coefficients are correlations between measures of different constructs using the same method or correlations between different constructs using different methods. To establish validity, convergent validities should be substantially higher than divergent validities. This method has been used in psychological research and has been accepted as an adequate evidence for validity. Therefore, researchers need to incorporate multiple and different data-gathering methodologies to more rigorously validate the measurement of patient satisfaction. Third, research control needs to be improved to advance the acquisition of information regarding patient satisfaction. To date, the majority of studies in patient satisfaction is correlational in nature. The
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relationship between a predictor (eg, an intervention) and patient satisfaction is generally confounded by numerous factors, such as age, gender, health status, and extent of family involvement in the delivery of care. Carefully selected control variables that may have an impact on patient satisfaction have to be taken into account in the research design and statistical analyses in future research. Finally, longitudinal research is needed to understand the stability of patient satisfaction and which factors could have an direct impact on it. Patients' perceptions of satisfaction, changes in their levels of satisfaction, and their subsequent behaviors can be better understood in such a research design. Conclusion
Should patient satisfaction be an indicator of quality of care? The Joint Commission on Accreditation of Healthcare Organizations (1988) has identified the criteria for selecting indicators of quality of care: "For monitoring and evaluation to be effective, the indicators must be well-defined, comprehensive, objective and specific, clinically valid, relevant and efficient" (p. 59). Moreover, Meisenheimer (1992) maintains that the indicators of quality of care should be measurable and are necessary to determine if the care provided is of quality. However, the current research on patient satisfaction shows that the concept of patient satisfaction is ill-defined, not comprehensive, subjective and unspecific, not clinically valid, and may not be necessarily relevant to quality of care. Furthermore, a lack of a consistent definition of patient satisfaction and numerous methodological issues are major limitations that lead to confusion and result in problems in using patient satisfaction as an indicator of quality of care. Nevertheless, Donabedian (1987) believes that patients are the paramount consideration in defining the quality of interpersonal care but not technical care. Patients are the ultimate authorities in defining the criteria of good care in the interpersonal relationship dimension of in nursing care. Therefore, patient satisfaction functions as an attribute of quality per se--without it there can not be good care. Furthermore, patient satisfaction is an indicator of interpersonal care but not technical care. Finally, patient satisfaction is a prerequisite for achieving the goals of nursing care (Vouri, 1987). In conclusion, this article has examined numerous dilemmas that nursing evaluation researchers con-
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fronted when attempting to use patient satisfaction as an outcome variable in evaluating nursing care delivery and as an indicator of quality of nursing care. Based on the current situation regarding what we know about the nature of patient satisfaction, there are a number of problems in the use of patient satisfaction as an indicator of quality of care. Researchers have faced diverse unsolved dilemmas related to conceptual-
ization and methodology in measuring patient satisfaction. Consequently, it appears too presumptuous at this time to consider patient satisfaction as an indicator of quality of nursing care and as an outcome variable in nursing evaluation research. A tremendous amount of research effort is badly needed before patient satisfaction can be regarded as an appropriate indicator of quality of nursing care.
References
Abramowtz, S., Cote, A. A., & Berry, E. (1987). Analyzing patient satisfaction: A multianalytic approach. QRB: Quality ResearchBulletin, 19, 122-130. Aharony, L., & Strasser, S. (1993). Patient satisfaction: What we know about and what we still need to explore. Medical CareReview, 50, 49-79. Allen, M. J., & Yen, W. M. (1979). Introduction to measurement theory. Monterey, CA: Cole. Bader, M. M. (1988). Nursing care behaviors that predict patient satisfaction. Journal of Nursing Quality Assurance, 2, 11-17. Bartlett, E. E., Grayson, R., Barker, D. M., & Levine, A. (1984). The effects of physician communication skills on patient satisfaction, recall and adherence. Journal of Chronic Disease, 3Z 755-764. Bond, S., & Thomas, L. H. (1992). Measuring patients' satisfaction with nursing care. Journal of Advanced Nursing, IZ 52-63. Campbell, D. T., & Fiske, D. W. (1956). Convergent and discriminant validation by the multitrait-multimethod matrix. PsychologicalBulletin, 56, 81-105. Clear> P. D., Keroy, L., Karpanos, G., & McMullen, W. (1983). Patient assessment of hospital care. Quality Review Bulletin, 15, 172-179. Clear> P. D., & McNeil, B. J. (1988). Patient satisfaction as an indicator of quality of care. Inquiry, 25, 25-36. Cottrell, B. H., & Grubbs, L. M. (1994). Women's satisfaction with couplet care nursing compared to traditional postpartum care with rooming-in. Research in Nursing and Health, 1Z 401-409. DiStefano, M. K., Pryer, M. W., & Garrison, J. L. (1980). Psychiatric patients' and staffs perceptions of clients' satisfaction with hospital services. PsychologicalReports, 46, 1343-1344. Donabedian, A. (1980). Explorations in quality assessment and monitoring: Vol. I. The definition of quality and approaches to its assessment. Ann Arbor, MI: Health Administration Press. Donabedian, A. (1987). Commentary on some studies of the quality of care. Health Care Financing Review, 20(Suppl. 10), 75-85. Fox, J. G., & Storms, D. M. (1981). A different approach to sociodemographic predictors of satisfaction with health care. Social Science and Medicine, 15, 557-564. Greeneich, D. (1993). The link between new and return business and quality of care: Patient satisfaction. Advanced Nursing Studies, 16, 62-72.
Greeneich, D., Long, C., & Miller, B. (1992). Patient satisfaction update: Research applied to practice. Applied Nursing Research, 5, 43-48. Hinshaw, A. S., & Atwood, J. R. (1981). A patient satisfaction instrument: Precision by predication. Nursing Research, 3, 170-175. Joint Commission on Accreditation of Healthcare Organizations. (1988). The Joint Commission guide to quality assurance. Chicago: Author. La Monica, E. L., Oberst, M. T., Madea, A. R., & Wolf, R. M. (1986). Development of a patient satisfaction scale. Research in Nursing and Health, 9, 42- 50. Ley, P. J., Kinsey, S. T., & Atherton. (1976). Increasing patients' satisfaction with communication. BritishJournal of Social and Clinical Psychology, 15, 403-413. Lewis, K. E., & Woodside, R. E. (1992). Patient satisfaction with care in the emergency department. Journal ofAdvanced Nursing, 1Z 959-964. Marram, G. D., Flynn, K. T., Abaravich, W., & Carey, S. (1976). Cost effectiveness of primary and team nursing. Wakefield, MD: Contemporary Publishing. McDaniel, C., & Nash, J. G. (1990). Compendium of instruments measuring patient satisfaction with nursing care. QRB: Quality ResearchBulletin, 22, 182-188. Megivern, K., Halm, M. A., & Jones, G. (1992). Measuring patient satisfaction as an outcome of nursing care. Journal of Nursing Care Quality, 6, 9-24. Meisenheimer, C. G. (1992). Improving qual#y: A guide to effectiveprograms. Gaithersburg, MD: Aspen. Meterko, M., Nelson, E. C., & Rubin, H. R. (1990). Patient judgements of hospital quality. Medical Care, 28 (Suppl. 9). Munro, B. H., Jacobsen, B. S., & Brooten, D. A. (1994). Re-examination of the psychometric characteristics of the La Monica-Oberst patient satisfaction scale. Research in Nursing and Health, 17, 119-125. Pandiani, J. A., Kessler, R., Gordon, L., & Domkot, D. (1982). Monitoring client satisfaction: Ethical, political, and empirical issues. In H. Fishman (Ed.), Creativity and innovation. Davis, CA: Pyramid. Pascoe, G. C. (1983). Patient satisfaction in primary health care. Evaluation and Program Planning, 6, 185-210. Pearson, A., Durand, I., & Punton, S. (1989). Determining quality in a unit where nursing is the primary intervention. Journal of Advanced Nursing, 14, 269-273.
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Petersen, M. (1988). Measuring patient satisfaction: Collecting useful data. Journal of Nursing QualityAssurance, 2, 25-35. Richard, D. A., & Lambert, P. (1987). The nursing process: The effect on patients' satisfaction with nursing care. Journal ofAdvanced Nursing, 12, 559-562. Risser, N. (1975). Development of an instrument to measure patient satisfaction with nurses and nursing care in primary care settings. Nursing Research,24, 45-52. Rossi, P H., & Freeman, H. E. (1993). Evaluation."A systematicapproach. Newbbury Park, CA: Sage. Rubin, H. R. (1990). Patient evaluations of hospital care. Medical Care, 9, $3-$9. Scarding, S. A. (1994). SERVQUAL: A tool for evaluating patient satisfaction with nursing care. Journal ofNursing Care Quality, 8, 38-46. Swan, J. (1985). Deepening the understanding of hospital patient satisfaction: Fulfillment and equity effects. Journal of Health CareMarketing, 5, 7-18. Thompson, A. G. H. (1986). The soft approach to quality of hospital care. Health Care Management, 11, 10-14. Thompson, D. R. (1990). Counselling the coronary patient and partner. London, England: Scutari.
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Vouri, H. (1987). Patient satisfaction~An attribute or indicator of the quality of care? QualityReviewBulletin, 13, 106-108. Ward, S. E., & Gordon, D. (1994). Application of the American Pain Society quality assurance standards. Pain, 56, 299-3O6. Ware, J. E., Davies-Avery, A., & Stewart, A. (1978). The measurement and meaning of patient satisfaction. Health and Medical CareServiceReview, 1, 3-14. Ware, J. E., & Hays, R. D. (1988). Methods for measuring patient satisfaction with specific medical encounters. Medical Care, 26, 393-401. Ware, H. E., Snyder, M. K., Wright, W. R., & Allison, R. D. (1983). Defining and measuring patient satisfaction with medical care. Evaluation and Program Planning, 6, 247-263. Ware, J. E., Wright, M. K., & Snyder, (1975). Consumer perception of health care services: Implications for academic medicine. Journal of Medical Education, 9 (Suppl. 10), 839-848. Wartman, S. A. (1983). Patient understanding and satisfaction as predictors of compliance. Medical Care, 21, 886-891. Zeithaml, V., Parasuraman, A., & Berry, L. (1990). Deliveringquality service. New York: Macmillan.
Evaluation is one of the most critical phases of the nursing process because it supports the basis of the usefulness and effectiveness of nursing practice. Nursing practice is patient driven and patient centered. Accordingly, patient satisfaction has been strongly advocated by nursing professionals to be an important indicator of quality of nursing care delivery. This article discusses the conceptualization and measurement of patient satisfaction with nursing care. Also, this article examines numerous dilemmas related to conceptualization and methodology that nursing evaluation researchers confront when attempting to use patient satisfaction as an outcome variable. Based on the current knowledge regarding the nature of patient satisfaction, implications for future nursing evaluation research are proposed and discussed to overcome these dilemmas in measuring patient satisfaction as an indicator of quality of nursing care. (Index words: Evaluation research; Patient satisfaction; Quality assurance; Quality of care) J Prof Nurs
12:207-216, 1996. Copyright© 1996 by W.B. Saunders Company
VALUATION is one of the most critical phases of the nursing process. Evaluations serve at least the following three functions: determine the effectiveness of a program, assess the utility of a new program, and satisfy the accountability requirements of program sponsors (Rossi & Freeman, 1993). Therefore, to improve the quality of nursing care, evaluation is especially crucial because it supports the basis of the usefulness and effectiveness of nursing practice. As suggested by Donabedian (1980), "The degree of quality is the extent to which the care provided is expected to achieve the most favorable balance of risks and benefits" (p. 5). Donabedian divides quality of care into two domains: the technical and the interpersonal. Technical care (science of care) is the application of any science or technology of medicine to manage a
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*AssociateProfessor, School of Nursing, Taipei Medical College,Taiwan,ROC. Addresscorrespondenceand reprint requeststo Dr Lin: School of Nursing, Taipei Medical College, 250 Wu-Hsing St, Taipei, Taiwan, ROC. Copyright© 1996byW.B. SaundersCompany
8755-7223/96/1204-0007503.00/0
health problem; on the other hand, interpersonal care (art of care) refers to the management of the social and psychological interaction between client and practitioner. Donabedian also proposes a third element in the quality of care, which is called amenities, such as a pleasant and restful waiting room. However, he later considers this as part of interpersonal care. Donabedian's (1980) structure, process, and outcome framework provides a useful means for evaluating the quality of nursing care. He identifies three approaches in the evaluation of quality of care: structure, process, and outcome. First, structure of care is defined as "the relatively stable characteristics of the providers of care, of the tools and resources they have at their disposal, and of the physical and organizational settings in which they work" (p. 81). Structure of care includes resources such as the human resources, physical equipment, and finances that are needed to provide care. Second, Donabedian (1980) defines process of care as "a set of activities that goes on within and between practitioners and patients" (p. 79). Process can also be defined as normative behavior, which derives from the science of medicine or from the ethics and values of society (Donabedian). Process in quality of nursing care could be the activities of nurses in demonstrating their knowledge to patients and the degree to which nurses conform to their expectations and those of patients. The third approach is to evaluate the outcomes of quality of care. Outcome of quality is referred to as "a change in a patient's current and future health status and improvement of social and psychological function that can be attributed to antecedent health care" (Donabedian, 1980, p. 82). Donabedian suggests that the outcome approach to quality assessment can provide an integrative and inclusive measure of the quality of the program because many factors that contribute to the quality are reflected by the outcome approach. He further summarizes several functions of outcome measures. First of all, outcomes provide indirect measures of process of care because process is much more difficult to measure. Outcomes also
Journal of ProfessionaINursing, Vol 12, No 4 (July-August), 1996: pp 207-216
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provide a link between process and outcome in the monitoring method to determine if the monitoring system is measuring what it is supposed to measure. Last, outcome measures function to screen clients who require further assessment from those who do not. Nursing practice is patient driven and patient centered. Accordingly, patients' perceptions of quality of nursing care can contribute to the evaluation of quality of nursing care by determining the values that are to be placed on nursing care. The patient's perception of quality of nursing care is regarded as patient satisfaction, which has been strongly advocated by nursing professionals to be an important indicator of quality of nursing care delivery (McDaniel & Nash, 1990) and an important outcome measure of evaluation of nursing care.
• . . assessment of patient satisfaction has become progressively more
interesting to a number of researchers...
Purposes of Assessing Patient Satisfaction in Nursing and Other Disciplines In recent years, the assessment of patient satisfaction has become progressively more interesting to a number of researchers in evaluating the quality of nursing care. Reasons for assessing patient satisfaction with nursing care have been based on the following rationales. First, assessing patient satisfaction provides a means of monitoring quality of nursing care and evaluating effectiveness of nursing interventions (Cottrell & Grubbs, 1994; La Monica, Oberst, Madea, & Wolf, 1986). Patient satisfaction also has been described as an indicator of patient outcome (Megivern, Halm, & Hones, 1992). Moreover, because patient participation is a central tenet of nursing care, seeking patients' opinions is considered to be a therapeutic nursing activity (Bond & Thomas, 1992). In addition, market forces have prompted hospital facilities to focus on promoting patient satisfaction (Scarding, 1994). Last, satisfaction with nursing care is the most important predictor of overall satisfaction with hospital care (Abramowitz, Cote, & Berry, 1987; Greeneich, 1993). Other purposes and rationales of measuring patient satisfaction have also been proposed in other disci-
plines, such as medicine. Those purposes and rationales are that patients with high satisfaction with care or service are more likely to comply with medical regimens (Wartman, 1983), are more likely to participate in their treatment (Bartlett, Grayson, Barker, & Levine, 1984), and are more likely to return and continue to use the medical services (Ware, Wright, & Snyder, 1975). In addition to the focuses of patient compliance and competition among medical services, Donabedian (1980) also points out that patient satisfaction provides feedback for the quality assessment process and program evaluation.
Conceptualization of Patient Satisfaction With Nursing Care Similar to other disciplines, patient satisfaction has been conceptualized inconsistently across studies in nursing. Early in 1975, Risser first proposed a definition of patient satisfaction with nursing care, which was described as "the degree of congruency between a patient's expectations of ideal nursing care and his perception of the real nursing care he receives" (p. 46). This definition was later adopted by some other researchers (eg, Cottrell & Grubbs, 1994; Hinshaw & Atwood, 1981; La Monica et al., 1986; Scarding, 1994). A similar definition (Greeneich, Long, & Miller, 1992) is that patient satisfaction is expressed as the match between patient expectations of nursing care and the care actually received. Marram, Flynn, Abaravich, & Carey (1976) defined patient satisfaction as patients' satisfaction with their nursing care and the degree to which they believed it was individualized and personalized. Additionally, Petersen (1988) provided a more general definition and explained patient satisfaction as "patients' perceptions of how their care was provided, excluding the outcome of their health status or the appropriateness of their therapy" (p. 26). Also, several researchers (eg, Lewis & Woodside, 1992; Munro, Jacobsen, & Brooten, 1994; Richard & Lambert, 1987) have left the definition of patient satisfaction to be interpreted by the reader. Researchers, then, have incongruently conceptualized dimensions of patient satisfaction with nursing care. Risser (1975) conceptualized patient satisfaction with nursing care as having three dimensions when she developed an instrument measuring this concept: (1) technical-professional behaviors, eg, technical activities and the knowledge base required to competently complete the nursing care tasks; (2) a trusting relationship, eg, nursing characteristics that allow for constructive and comfortable patient-nurse interac-
PATIENT SATISFACTION AS AN OUTCOME VARIABLE
tion and communication aspects of the interaction; and (3) an educational relationship, eg, nurses' ability to provide information for patients, including answering questions, explaining care, and demonstrating techniques. This conceptualization of dimensions has been employed by some other researchers (Bader, 1988; Hinshaw & Atwood, 1981). Another conceptualization of factors related to patient satisfaction, derived from Risser's conceptual framework, was suggested by other investigators (La Monica et al., 1986; Munro, Jacobsen, & Brooten, 1994) to indude dissatisfaction, interpersonal support, and good impression. Moreover, Greeneich, Long, and Miller (1992) conducted a review of patient satisfaction instruments and proposed a nursing taxonomy of patient satisfaction, which includes the following three dimensions: (1) the nurse's inherent personality characteristics, nursing care characteristics, and nursing proficiency; (2) the patient's expectations; and (3) the organizational environment, ie, nursing milieu. Still others (Megivern et al., 1992; Petersen, 1988) adopted a conceptual framework originating in the medical discipline (Ware, Davies-Avery, & Stewart, 1978) and describing patient satisfaction with nursing care as involving the following dimensions: art of care, accessibility and convenience, finances, physical environment, availability, continuity of care, and efficacy and outcomes of care. Adopting a marketing service perspective (Zeithaml, Parasuraman, & Berry, 1990), Scarding (1994) suggested that patient satisfaction with nursing care included five dimensions: (1) tangible, eg, the appearance of physical facilities, equipment, personnel, and communication materials; (2) reliability, eg, the ability to perform the promised service dependably and accurately; (3) responsiveness, eg, the willingness to help customers and to provide prompt service; (4) assurance, eg, the knowledge and courtesy of employers and their ability to convey trust and confidence; and (5) empathy, eg, the provision of caring, individualized attention to customers. Finally, some researchers (Lewis & Woodside, 1993; Richard & Lambert, 1987) have left the dimensions of patient satisfaction undefined. It is apparent that the construct of patient satisfaction is not consistently and clearly conceptualized. Most of the constructs of patient satisfaction have neither been replicated in other research nor well supported. Also, no researchers have specified the mechanisms by which patient satisfaction develops. Moreover, none of the constructs have discussed the nature (eg, a behavior or a belief/attitude) and the stability (change over time or stable) of patient
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satisfaction. Last, no directional hypotheses for testing patient satisfaction have yet been developed and tested. Instruments for Measuring Patient Satisfaction With Nursing Care
Most of the patient satisfaction instruments available to nursing are ordinal scales and are measured by rating on a Likert or Likert-type scale. One instrument rates satisfaction on a three-point scale ranging from "very satisfactory" to "not satisfactory" (Lewis & Woodside, 1992). Some instruments use a five-point scale ranging from "strongly agree" to "strongly disagree" (Hinshaw & Atwood, 1981; Munro, Jacobsen, & Brooten, 1994; Risser, 1975) or ranging from "poor" to "excellent" (Megivern et al., 1992). Some tools use a seven-point scale (from "strongly agree" to "strongly disagree" or from "very dissatisfied" to "very satisfied") (Cottrell & Grubbs, 1994; La Monica et al., 1986; Scarding, 1994). Only a few instruments have reported reliability and validity; however, many of them have not (Lewis & Woodside, 1992; Megivern et al., 1992). Risser (1975) developed the first standardized patient satisfaction measurement specific to nursing care. The 25-item Patient Satisfaction Scale (PSC) was originally developed to test four dimensions: technicalprofessional behavior, interpersonal-interpersonal relationship, trusting relationship, and educational relationship. However, in a later modification the intrapersonal-interpersonal relationship dimension was dropped without further explanation. This instrument was tested on 138 patients in primary health care settings. The reliability of the PSC was established by using Cronbach's alpha, which ranged from .63 to .91. Only the content validity was mentioned. No other types of validity were tested. The Patient Satisfaction Instrument (PSI) (Hinshaw & Arwood, 1981) was developed by revising one item on the PSC in order for it to be used with inpatient hospital patients. In the item, "The nurse gives good advice over the telephone," the phrase "over the telephone" was deleted. The PSI was tested in five studies with a total of 600 patients, primarily medical surgical inpatients and outpatients. Scores of patient satisfaction were highly positively skewed. The reliability estimated by internal consistency (Cronbach's alpha) ranged from .44 to .98. Several approaches were undertaken to estimate the validity. Multitrait monomethod was used to estimate the convergent and divergent validity by correlating the
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three constructs in the instrument (education, trusting, and technical-professional) with other different constructs (patient physical condition, direct care quality-nurse, and direct care-patient). It was found that the convergent validity coefficients were generally higher than the divergent validity coefficients. It then was concluded that this result provided an estimate of moderate to strong construct validation for the PSI. However, the measurements for heterotrait constructs (eg, patient physical condition) were not specified. Also, one of the reliability coefficients (direct care quality-patient) was lower than the convergent validity coefficient. Furthermore, the discriminate validity was estimated in three studies by examining the differences of patient satisfaction in three phases. The predicted differences were not found in one study. Intercorrelations among the three constructs (education, trusting, and technical-professional) were performed to assess the consistency within the instrument. It was found that the subscale-subscale correlation coefficients ranged from .28 to .90. In a 21 correlation matrix, seven of the coefficients exceeded .70, which means that there is considerable conceptual overlapping between the two constructs, especially between the technical-professional construct and the trusting construct.
. . . it is not appropriate to base validity on a significant t e s t . . .
The La Monica-Oberst Patient Satisfaction Scale (LOPSS) was originally developed to assess three dimensions of patient satisfaction based on Risser's conceptualization. However, the confirmatory factor analysis did not support this conceptualization, and the exploratory factor analysis generated other three factors: dissatisfaction, interpersonal support, and good impression. This instrument was tested on a total of 633 hospitalized oncology patients, and scores on the scale were highly positively skewed. Internal consistency ranged from .92 to .95. Construct validity was estimated by correlating patient satisfaction scores with mood scores (anxiety, depression, and hostility) measured by the Multiple Affect Adjective Check List (MAACL). Correlations between these two constructs were essentially low (-.20, -.21, and -.27). The authors claimed that although these correlations were not high, all were significant. Nevertheless, it is not appropriate to base validity on a significant test
because a significant correlation indicates only that the correlation is different from zero instead of high enough to establish validity. Additionally, the construct validity of the MAACL has not been well established and documented. Thus, the MAACL should not be used to test the validity of another construct because it is not appropriate to correlate two instruments, neither of which has established validity data (Allen & Yen, 1979). Last, the authors named this form of validity "discriminate validity," which seems to be a mistake. Munro, Jacobsen, and Brooten (1994) then reexamined the psychometric properties of the LOPSS on a total sample of 307 patients who had various conditions. Again, scores were highly positively skewed. Factor analysis generated only two factors: interpersonal support and dissatisfaction. Reliability (Cronbach's alpha) was .97 for the total instrument. Subscale internal consistency was not reported. The convergent validity was estimated by correlating the total score with the score on a single item that measured overall satisfaction and was found to be .32 to .46, an acceptable level. Nonetheless, this form of convergent validity provides only very weak evidence for validity. Cottrell and Grubbs (1994) modified the Risser Patient Satisfaction Instrument (1975) to adjust the nursing practice of a postpartum unit. Items were placed into four dimensions: communication, teaching, professional behaviors, and nurses' skills. Another revision was made to use a seven-point Likert-type scale instead of a five-point scale. Cronbach's alpha coefficients ranged from .80 to .97. Only content validity was established. Also, the subscale-subscale correlation coefficients were not reported. Scores on the scale were positively skewed. Scarding (1994) adopted the SERVQUAL from a marketing perspective. This instrument measures five dimensions: tangibles, reliability, responsiveness, assurance, and empathy. This measure was tested on a convenience sample of 10 postoperative cardiothoratic patients. Reliability was established by internal consistency ranging from .40 to .98. Only face validity and content validity were mentioned. Because of the extremely small sample size, the interpretation of reliability and validity becomes meaningless. The review of the existing instruments of patient satisfaction used in nursing shows that reliability and validity have posed a number of problems, which may be related to conceptualization. Reliability has been estimated only by internal consistency (Cronbach's alpha). No test-retest reliability has yet been estimated. The lack of an appropriate theoretical frame-
PATIENT SATISFACTION AS AN OUTCOME VARIABLE
work introduces difficulties in testing validity. As a result, in some instruments only face and content validity were mentioned. Most of the researchers failed to provide strong evidence for validity.
Factors Influencing Patient Satisfaction
Rubin (1990) suggests that several factors could influence patients' judgments of their satisfaction, including timing of survey, response format, and nonrespondence. Some other factors, such as demographic variables, expectations, general health status, and care delivered, have also been found in the literature to be related to patient satisfaction. TIMING OF SURVEY
Researchers have found that patients who were assessed at different points during their hospital stay or after discharge responded differently on measures of patient satisfaction. They found that patients surveyed during their stay or several months after discharge expressed greater satisfaction than did patients who had been discharged a few weeks before the survey was conducted (Ley, Kinsey, & Atherton, 1976). RESPONSE FORMAT
Rubin (1990) reports that no comparisons have been made among different response formats in eliciting patient ratings of satisfaction. Nevertheless, he suggests the potential advantages of using an "excellent-poor" scale over using an "agree-disagree" scale. For example, Ware and Hays (1988) found that "excellent-poor" scales with a neutral item stem elicited greater variance, were less skewed, and were more highly related to patients' behavioral intentions concerning health care than were direct scales of "very satisfied-not at all satisfied." NONRESPONDENCE
To date, there has been little research addressing whether a difference of patient satisfaction ratings exists between respondents and nonrespondents. However, it has been maintained that nonrespondents may be less satisfied with care than respondents (Ley, Kinsey, & Atherton, 1976). On the other hand, some researchers (Ware, Snyder, Wright, & Allison, 1983) found that patients who were more satisfied with their received care were less likely to return questionnaires.
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DEMOGRAPHIC VARIABLES
Demographic characteristics, such as age, gender, education, and race, appear to affect patients' ratings of satisfaction. These factors, however, have been reported to relate with patient satisfaction inconsistently. For example, Ware et al. (1978) concluded that relationships existed between many sociodemographic characteristics and satisfaction with dimensions of care. In contrast, Fox and Storms (1981) asserted that these demographic variables were characterized as chaotic and not having consistent relationships. It was reported that older patients were more likely to rate higher satisfaction (Pascoe, 1983); however, other researchers did not support this finding (Bader, 1988; Clear~ Kero)~ Karpanos, & McMullen, 1983). Furthermore, women were found to be more likely to be satisfied with care than were men (Pandiani, Kessler, Gordon, & Domkot, 1982); on the other hand, other researchers (Bader, 1988; DiStefano, Pryer, & Garrison, 1980) did not find any relationship between gender and satisfaction. EXPECTATIONS
Commonly, it is believed that satisfaction is related to expectations. Studies that explored the relationship between patient expectations and satisfaction showed that patients with lower expectations and restricted knowledge of services available are more likely to be more satisfied, whereas, those with higher or unrealistic expectations are less likely to be satisfied (Swan, 1985). GENERAL HEALTH STATUS
Health status is often thought to affect patients' ratings of satisfaction. Several studies have shown that a positive relationship exists between satisfaction and general health (Tompson, 1990). Cleary et al. (1983) found that perceived health was a strong predictor of overall satisfaction. On the other hand, some studies showed no relationship between health status and satisfaction (Fox & Storms, 1981). CARE RECEIVED
Recently, patient satisfaction has been used to evaluate health care as well as nursing practice. Although little research indicates that patients' satisfaction is related to perceptions of the provider's competence and technical skills (Meterko, Nelson, & Rubin, 1990), Ware, Wright, and Snyder (1975) found that patients were not able to evaluate providers' technical
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skills. For example, Ward and Gordon (1994) found that there was very little association between pain severity experienced by patients and patients' satisfaction with pain management, which means that these patients were satisfied with the pain management provided by their clinicians while they were concurrently suffering from moderate to extreme pain. It has been asserted that in general patient satisfaction is related to perceived interpersonal and communication skills (Cleary & McNeil, 1988). As a result, interpersonal and communication skills are the most frequently emphasized variables related to patient satisfaction. Several studies have supported this assertion. Patient satisfaction has been consistently found to be positively related to interpersonal skills, such as being caring and sensitive (eg, Passkey, 1985), and communicating clearly. Providing dear communication has been found to be one of the most important elements of overall satisfaction (eg, Cleary & McNeil,
1988). Bader (1988) conducted a survey that explored which nursing care behaviors predict patient satisfaction. Patients identified 15 nursing behaviors related to their satisfaction with nursing care. It was found that 12 of these were affective activities, such as being attentive, being friendly, and providing clear explanation. Only three of the behaviors were professional or technical activities, such as being skillful. Cottrell and Grubbs (1994) compared patient satisfaction with two types of postpartum nursing care: traditional nursing with rooming-in versus couplet nursing care. They found that patient satisfaction scores were highly positively skewed in both groups. Patients in both groups were highly satisfied with nursing care, with no difference in satisfaction between groups. The studies reviewed in this section provide evidence that patient satisfaction is more likely to be predicted by non-care-related factors, such as demographic variables, timing of survey, and expectations. However, variability and inconsistency characterize the results. Among the care-related variables, factors related to interpersonal care, such as interpersonal and communication skills, were much more strongly predictive of patient satisfaction than were technical care. This conclusion supports Donabedian's (1987) argument that patients are the paramount consideration in defining the quality of the interpersonal processes and of the amenities of care, but it does not consider patients' ability to judge the quality of technical areas of care. However, in general the studies reviewed have been characterized by a lack of conceptual clarity in
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both predictor and outcome variables with consequent diversity of findings. There is also no consistency in the way in which patient satisfaction is measured.
Problems in Using Patient Satisfaction As an Outcome Variable
Despite the increasing interest in evaluation among researchers who measure patient satisfaction, those who suspect the value of including patient satisfaction measures as indicators of quality of care have pointed to a number of factors that potentially limit the validity of this approach and have explained the reluctance to include patient satisfaction among quality of care criteria. Vouri (1987) summarized several problems caused by including patient satisfaction in quality assurance. Patients lack the scientific and technical knowledge necessary to adequately assess quality of care. Patients may be in physical or mental states that make them incapable of passing objective judgments. The rapid pace of events--nursing interventions, diagnostic tests, therapeutic measures--makes it difficult for patients to have a comprehensive and objective view of what is going on. Care providers and patients may have different goals for care; patients' wishes may be harmful or not in their best interest from the care provider's perspective. Patient satisfaction cannot be measured in a way that would yield useful results because it is difficult--if not impossible--to define what "quality" means to patients. The concept is dependent on many different patient characteristics, varying with age, sex, education, and socioeconomic status, varying between the stages of being critically ill to being well on the way to recovery. M1 of these variables bring the empirical validity of assessing patient satisfaction into question (p. 106). METHODOLOGICAL DILEMMAS IN MEASURING PATIENT SATISFACTION
Lack of a Consistent Conceptualization and an Appropriate Theoretical Framework
To date, there is no consensus about the definition and conceptualization of patient satisfaction. It has been pointed out that very little satisfaction research is theory-testing or theory-building (Aharony & Strasser, 1993). A lack of attention has been given to the conceptualization of patient satisfaction. Most researchers, thus far, are predominately interested in identifying sociodemographic factors rather than developing a theory. Without a consistent conceptualization and an accepted theory, the concept of patient satisfaction can
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PATIENT SATISFACTIONAS AN OUTCOME VARIABLE
not be adequately measured; thus, knowledge generation in this area is difficult. Also, research questions or hypotheses can not be justified or driven without a sound theol-F Furthermore, there is no consensus regarding which conceptual facets the concept of patient satisfaction encompasses (Bond & Thomas, 1992). Finally, no theorists have hypothesized and predicted the mechanism for forming patient satisfaction judgment and subsequent reaction (Aharony & Strasser, ! 993). Lack of a Reliable and Valid Approach to Measure Patient Satisfaction
The issue of reliability and validity of measures of patient satisfaction has posed a number of conceptual and operational problems for evaluation researchers across all disciplines, including nursing. Researchers have failed to provide adequate evidence for the reliability and validity of patient satisfaction measures. Most researchers have tested only internal consistency, whereas test-retest reliability has rarely been reported. Also, a number of researchers do not provide information regarding the reliability of their instruments.
A lack of attention has been given to the conceptualization of patient satisfaction.
Testing validity of patient satisfaction measures is a challenging task for researchers because of a lack of clarity in conceptualization and a lack of an appropriate theory. As Thompson (1986) has pointed out, patient satisfaction measurement generally lacks methodological as well as conceptual soundness, which makes examining validity of instruments perplexing. The review shows that several investigators failed to examine validity; however, some investigators attempted to establish validity by using a weak design. For example, some researchers tested validity by comparing a total patient satisfaction score with a single item score. The convergent validity alone indicates only very weak validity. Similar to testing divergent validity alone, some researchers reported only the correlation between the patient satisfaction construct and a different construct. Moreover, several investigators intended to establish construct validity by comparing patient satisfaction with another construct; unfortunately, neither of these constructs has established validity.
Because the ways of validating patient satisfaction measurement are not satisfying researchers, some researchers have made multiple efforts to overcome this problem and have provided suggestions. However, these solutions have limited potential success because of the constraint of a lack of theoretical framework. For example, Bond and Thomas (1992) recommend that researchers establish validity by comparing patient satisfaction with other variables, such as health care outcomes, compliance, and intention to return. Unfortunately, none of these variables has existing established valid measurement. Moreover, these constructs appear to be conceptually and logically distinct from patient satisfaction. Finally, the author has no justification for using intention to return as an criterion because patients tend to resist change. Once patients are more familiar with the hospital facility and the care, they are very unlikely to change the care unless they are highly dissatisfied. Insensitivity of Patient Satisfaction Measurements
The majority of existing tools have been found to be insensitive to discriminating patient satisfaction; namely, they generate highly positively skewed scores (Cottrell & Grubbs, 1994; La Monica et al., 1986; Scarding, 1994). No matter how good or bad the nursing care is, patients are generally highly satisfied. This bias is believed to be related to social desirability; which means that patients wish to please staff and fear repercussions for negative care appraisal (Pearson, Durand, & Punton, 1989). Therefore, different formats of measurement or different modes of administration may be needed to increase the sensitivity of patient satisfaction instruments.
Implications for Nursing Elevation Research Emphasis on patient satisfaction with nursing care as an indicator of quality of nursing care is increasing as evidenced by the greater frequency of empirical publications on the topic and the widespread use of measures of patient satisfaction by nursing evaluators. However, nursing evaluation researchers are confronted by a number of perplexing problems, such as a lack of consensus on the role of patient satisfaction in evaluating the quality of nursing care and numerous methodological dilemmas. If nursing evaluation researchers continue to consider patient satisfaction as
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an indicator of quality of nursing care, research efforts are needed to overcome a number of barriers that can potentially limit the validity of this approach. First, rigorous research needs to be undertaken to develop a theoretical framework of patient satisfaction that clearly defines the concept of patient satisfaction, specifies the conceptual facets patient satisfaction encompasses, and describes mechanisms for forming patient satisfaction judgements and subsequent reactions. With an appropriate theory, hypotheses and research questions can be driven and tested, and instrument validity can be rigorously established. Second, a reliable and valid tool for measuring patient satisfaction must be developed. Adequate evidence has to be provided to establish the reliability and validity of measures. Without a reliable and valid tool, the concept of patient satisfaction becomes unmeasurable, and information provided is meaningless. The test of validity of patient satisfaction measurement has been constrained by a lack of an appropriate theoretical framework. One possible solution proposed by the author to overcome this limitation is the use of the multitrait-multimethod process, which can provide strong evidence of construct validity. The multitrait-multimethod process was first developed by Campbell and Fiske (1956) and designed to judge the adequacy of a test as a measure of a construct. The basic idea of multitrait-multimethod validity is that a construct should be related to certain traits and unrelated to other traits. The researcher specified a priori a list of multiple ways to measure the construct and some distinctly different constructs that can be measured by the same methods. Convergent validity coefficients are correlations between measures of the same construct using different methods. Divergent validity coefficients are correlations between measures of different constructs using the same method or correlations between different constructs using different methods. To establish validity, convergent validities should be substantially higher than divergent validities. This method has been used in psychological research and has been accepted as an adequate evidence for validity. Therefore, researchers need to incorporate multiple and different data-gathering methodologies to more rigorously validate the measurement of patient satisfaction. Third, research control needs to be improved to advance the acquisition of information regarding patient satisfaction. To date, the majority of studies in patient satisfaction is correlational in nature. The
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relationship between a predictor (eg, an intervention) and patient satisfaction is generally confounded by numerous factors, such as age, gender, health status, and extent of family involvement in the delivery of care. Carefully selected control variables that may have an impact on patient satisfaction have to be taken into account in the research design and statistical analyses in future research. Finally, longitudinal research is needed to understand the stability of patient satisfaction and which factors could have an direct impact on it. Patients' perceptions of satisfaction, changes in their levels of satisfaction, and their subsequent behaviors can be better understood in such a research design. Conclusion
Should patient satisfaction be an indicator of quality of care? The Joint Commission on Accreditation of Healthcare Organizations (1988) has identified the criteria for selecting indicators of quality of care: "For monitoring and evaluation to be effective, the indicators must be well-defined, comprehensive, objective and specific, clinically valid, relevant and efficient" (p. 59). Moreover, Meisenheimer (1992) maintains that the indicators of quality of care should be measurable and are necessary to determine if the care provided is of quality. However, the current research on patient satisfaction shows that the concept of patient satisfaction is ill-defined, not comprehensive, subjective and unspecific, not clinically valid, and may not be necessarily relevant to quality of care. Furthermore, a lack of a consistent definition of patient satisfaction and numerous methodological issues are major limitations that lead to confusion and result in problems in using patient satisfaction as an indicator of quality of care. Nevertheless, Donabedian (1987) believes that patients are the paramount consideration in defining the quality of interpersonal care but not technical care. Patients are the ultimate authorities in defining the criteria of good care in the interpersonal relationship dimension of in nursing care. Therefore, patient satisfaction functions as an attribute of quality per se--without it there can not be good care. Furthermore, patient satisfaction is an indicator of interpersonal care but not technical care. Finally, patient satisfaction is a prerequisite for achieving the goals of nursing care (Vouri, 1987). In conclusion, this article has examined numerous dilemmas that nursing evaluation researchers con-
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PATIENT SATISFACTION AS AN OUTCOME VARIABLE
fronted when attempting to use patient satisfaction as an outcome variable in evaluating nursing care delivery and as an indicator of quality of nursing care. Based on the current situation regarding what we know about the nature of patient satisfaction, there are a number of problems in the use of patient satisfaction as an indicator of quality of care. Researchers have faced diverse unsolved dilemmas related to conceptual-
ization and methodology in measuring patient satisfaction. Consequently, it appears too presumptuous at this time to consider patient satisfaction as an indicator of quality of nursing care and as an outcome variable in nursing evaluation research. A tremendous amount of research effort is badly needed before patient satisfaction can be regarded as an appropriate indicator of quality of nursing care.
References
Abramowtz, S., Cote, A. A., & Berry, E. (1987). Analyzing patient satisfaction: A multianalytic approach. QRB: Quality ResearchBulletin, 19, 122-130. Aharony, L., & Strasser, S. (1993). Patient satisfaction: What we know about and what we still need to explore. Medical CareReview, 50, 49-79. Allen, M. J., & Yen, W. M. (1979). Introduction to measurement theory. Monterey, CA: Cole. Bader, M. M. (1988). Nursing care behaviors that predict patient satisfaction. Journal of Nursing Quality Assurance, 2, 11-17. Bartlett, E. E., Grayson, R., Barker, D. M., & Levine, A. (1984). The effects of physician communication skills on patient satisfaction, recall and adherence. Journal of Chronic Disease, 3Z 755-764. Bond, S., & Thomas, L. H. (1992). Measuring patients' satisfaction with nursing care. Journal of Advanced Nursing, IZ 52-63. Campbell, D. T., & Fiske, D. W. (1956). Convergent and discriminant validation by the multitrait-multimethod matrix. PsychologicalBulletin, 56, 81-105. Clear> P. D., Keroy, L., Karpanos, G., & McMullen, W. (1983). Patient assessment of hospital care. Quality Review Bulletin, 15, 172-179. Clear> P. D., & McNeil, B. J. (1988). Patient satisfaction as an indicator of quality of care. Inquiry, 25, 25-36. Cottrell, B. H., & Grubbs, L. M. (1994). Women's satisfaction with couplet care nursing compared to traditional postpartum care with rooming-in. Research in Nursing and Health, 1Z 401-409. DiStefano, M. K., Pryer, M. W., & Garrison, J. L. (1980). Psychiatric patients' and staffs perceptions of clients' satisfaction with hospital services. PsychologicalReports, 46, 1343-1344. Donabedian, A. (1980). Explorations in quality assessment and monitoring: Vol. I. The definition of quality and approaches to its assessment. Ann Arbor, MI: Health Administration Press. Donabedian, A. (1987). Commentary on some studies of the quality of care. Health Care Financing Review, 20(Suppl. 10), 75-85. Fox, J. G., & Storms, D. M. (1981). A different approach to sociodemographic predictors of satisfaction with health care. Social Science and Medicine, 15, 557-564. Greeneich, D. (1993). The link between new and return business and quality of care: Patient satisfaction. Advanced Nursing Studies, 16, 62-72.
Greeneich, D., Long, C., & Miller, B. (1992). Patient satisfaction update: Research applied to practice. Applied Nursing Research, 5, 43-48. Hinshaw, A. S., & Atwood, J. R. (1981). A patient satisfaction instrument: Precision by predication. Nursing Research, 3, 170-175. Joint Commission on Accreditation of Healthcare Organizations. (1988). The Joint Commission guide to quality assurance. Chicago: Author. La Monica, E. L., Oberst, M. T., Madea, A. R., & Wolf, R. M. (1986). Development of a patient satisfaction scale. Research in Nursing and Health, 9, 42- 50. Ley, P. J., Kinsey, S. T., & Atherton. (1976). Increasing patients' satisfaction with communication. BritishJournal of Social and Clinical Psychology, 15, 403-413. Lewis, K. E., & Woodside, R. E. (1992). Patient satisfaction with care in the emergency department. Journal ofAdvanced Nursing, 1Z 959-964. Marram, G. D., Flynn, K. T., Abaravich, W., & Carey, S. (1976). Cost effectiveness of primary and team nursing. Wakefield, MD: Contemporary Publishing. McDaniel, C., & Nash, J. G. (1990). Compendium of instruments measuring patient satisfaction with nursing care. QRB: Quality ResearchBulletin, 22, 182-188. Megivern, K., Halm, M. A., & Jones, G. (1992). Measuring patient satisfaction as an outcome of nursing care. Journal of Nursing Care Quality, 6, 9-24. Meisenheimer, C. G. (1992). Improving qual#y: A guide to effectiveprograms. Gaithersburg, MD: Aspen. Meterko, M., Nelson, E. C., & Rubin, H. R. (1990). Patient judgements of hospital quality. Medical Care, 28 (Suppl. 9). Munro, B. H., Jacobsen, B. S., & Brooten, D. A. (1994). Re-examination of the psychometric characteristics of the La Monica-Oberst patient satisfaction scale. Research in Nursing and Health, 17, 119-125. Pandiani, J. A., Kessler, R., Gordon, L., & Domkot, D. (1982). Monitoring client satisfaction: Ethical, political, and empirical issues. In H. Fishman (Ed.), Creativity and innovation. Davis, CA: Pyramid. Pascoe, G. C. (1983). Patient satisfaction in primary health care. Evaluation and Program Planning, 6, 185-210. Pearson, A., Durand, I., & Punton, S. (1989). Determining quality in a unit where nursing is the primary intervention. Journal of Advanced Nursing, 14, 269-273.
216
Petersen, M. (1988). Measuring patient satisfaction: Collecting useful data. Journal of Nursing QualityAssurance, 2, 25-35. Richard, D. A., & Lambert, P. (1987). The nursing process: The effect on patients' satisfaction with nursing care. Journal ofAdvanced Nursing, 12, 559-562. Risser, N. (1975). Development of an instrument to measure patient satisfaction with nurses and nursing care in primary care settings. Nursing Research,24, 45-52. Rossi, P H., & Freeman, H. E. (1993). Evaluation."A systematicapproach. Newbbury Park, CA: Sage. Rubin, H. R. (1990). Patient evaluations of hospital care. Medical Care, 9, $3-$9. Scarding, S. A. (1994). SERVQUAL: A tool for evaluating patient satisfaction with nursing care. Journal ofNursing Care Quality, 8, 38-46. Swan, J. (1985). Deepening the understanding of hospital patient satisfaction: Fulfillment and equity effects. Journal of Health CareMarketing, 5, 7-18. Thompson, A. G. H. (1986). The soft approach to quality of hospital care. Health Care Management, 11, 10-14. Thompson, D. R. (1990). Counselling the coronary patient and partner. London, England: Scutari.
CHIA-CHIN LIN
Vouri, H. (1987). Patient satisfaction~An attribute or indicator of the quality of care? QualityReviewBulletin, 13, 106-108. Ward, S. E., & Gordon, D. (1994). Application of the American Pain Society quality assurance standards. Pain, 56, 299-3O6. Ware, J. E., Davies-Avery, A., & Stewart, A. (1978). The measurement and meaning of patient satisfaction. Health and Medical CareServiceReview, 1, 3-14. Ware, J. E., & Hays, R. D. (1988). Methods for measuring patient satisfaction with specific medical encounters. Medical Care, 26, 393-401. Ware, H. E., Snyder, M. K., Wright, W. R., & Allison, R. D. (1983). Defining and measuring patient satisfaction with medical care. Evaluation and Program Planning, 6, 247-263. Ware, J. E., Wright, M. K., & Snyder, (1975). Consumer perception of health care services: Implications for academic medicine. Journal of Medical Education, 9 (Suppl. 10), 839-848. Wartman, S. A. (1983). Patient understanding and satisfaction as predictors of compliance. Medical Care, 21, 886-891. Zeithaml, V., Parasuraman, A., & Berry, L. (1990). Deliveringquality service. New York: Macmillan.