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To summarize the scientific literature on the elements essential to understanding a nursing definition of patient satisfaction.
Whittemore and Knafl's methodology was used for this integrative review.
Articles were included if the studies they explored patient satisfaction in patient populations and measured patient satisfaction using standardized, validated instruments. Elements in this review were defined as the essential components that create the complex concept of patient satisfaction.
Thirty articles were found and analysed in full. Five definitions of patient satisfaction were used, all of which were at least 20 years old. Twenty‐two different measures of patient satisfaction were used, six of which were nursing‐specific. Sixty‐eight elements of patient satisfaction were studied in the included articles. Forty‐three elements were reported as having a significant relationship with patient satisfaction, 25 were reported as having no significant relationship. Eight elements had both significant and non‐significant relationships.
Keywords: integrative review, measure development, nursing, patient satisfaction, quality of nursing care
Nurses have a major role in creating patient satisfaction. Butler et al. (2018) found critical care nurses spent 44.3% of their daytime working hours in or immediately outside a patient's room. This is more than double the time of physicians (14.7%), and other critical staff, including respiratory and physical therapists (20.5%). When patients were receiving direct care, 86.1% of the time it was with a nurse (Butler et al., 2018). A large portion of patient satisfaction may well be formed while under a nurse's direct care. The standardized evaluation of patient satisfaction in the United States, through Press Ganey and the introduction of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) in 2006, has changed how nursing performance is measured. The problem of standardization is not just within the United States, however; there is no single globally agreed‐upon definition or measure of patient satisfaction. Understanding the elements of patient satisfaction can help researchers, practitioners and administrators focus their efforts on where nurses can actually make a difference in patient satisfaction.
To improve nursing care and patient outcomes, researchers have been working to define patient satisfaction and create measures to quantify it for more than five decades (Abdellah & Levine, 1957; Bernays, 1947; Copp, 1971; McGhee, 1961: Ozturk et al., 2020). In the United States (U.S.), patient satisfaction surveys are currently used to evaluate the quality of healthcare received by the patient and nursing job performance and as part of the Medicare formula for hospital reimbursement (Petrullo et al., 2012). Hospitals that receive Medicare funding are required to participate in HCAHPS. More than 4,000 community hospitals in the United States participated in the HCAHPS survey programme in 2020 (Centers for Medicare and Medicaid Services, 2020a). The results of HCAHPS are shared publicly to aid consumers in healthcare decisions. In addition, Press Ganey surveys 40 million patients annually about their experience with different types of healthcare providers (Press Ganey, 2021). Press Ganey satisfaction surveys, while not shared publicly, are frequently used to evaluate nursing care on a unit level and can be part of nursing manager performance reviews. Hospital administrators often allocate resources and set nursing policy based on the findings from these patient satisfaction surveys (Gray et al., 2016).
Hospital Consumer Assessment of Healthcare Providers and Systems uses a 27‐question self‐reported feedback survey to gather data from patients who have been discharged. There is particular emphasis placed on the question of whether the patient would “recommend this hospital to your friends and family” (Centers for Medicare and Medicaid Services, 2020b, p. 323). Press Ganey uses similar questions and emphasis. The “would you recommend” question is used more broadly in marketing to measure brand loyalty and predict company growth (Reichheld, 2003). Using it in the healthcare setting, however, assumes that customer loyalty is equivalent to patient satisfaction. This points to a gap. A nursing‐specific measure of patient satisfaction would measure the patient's perspective of nursing care, as opposed to their perspectives on marketing or the hospital environment, over which nurses have little or no influence.
The concept of patient satisfaction, despite the five decades of work, lacks an agreed‐upon definition (Turris, 2005; Wolf et al., 2014). Without an explicit definition, it would be difficult to determine elements, that is, the conceptual content (Audi, 2015), of patient satisfaction. It would likewise be difficult (if not impossible) to measure patient satisfaction without conceptual content. Elements are the building blocks of a concept, without which, the concept would not be complete. A myriad of elements of care could influence a patient's perception of satisfaction, from food choices to waiting times to the personalities of caregivers and patients themselves. However, given the weight placed upon patient satisfaction, it is important to summarize the scientific literature vis‐à‐vis the elements of the concept of patient satisfaction.
The purpose of this integrative review was to summarize the scientific literature on the elements essential to understanding a nursing definition of patient satisfaction.
Whittemore and Knafl's (2005) methodology was used for this integrative review. The criteria for reporting this review followed the guidelines of the Preferred Reporting for Systemic Reviews and Meta‐Analysis (PRISMA).
The literature search was conducted from November–December of 2020 using Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PubMed databases. The search was updated on June 26, 2021, where no additional articles were found that fit the inclusion criteria. Table 1 presents the search terms and Boolean operators used in the search strategy, which were guided by a nursing librarian.
Boolean operator terms
| Search # | Terms |
|---|---|
| 1 | patient satisfaction AND mapping analysis |
| 2 | patient satisfaction AND (definition or define or meaning or description) |
| 3 | patient satisfaction AND (definition or define or meaning or description) AND (inpatients or hospitalized patients or hospitalized patients) |
| 4 | TI define patient satisfaction OR AB define patient satisfaction |
| 5 | (MH “Patient Satisfaction+”) AND (MH “Nursing Care+”) |
| 6 | (MH “Patient Satisfaction+”) AND (MH “Nursing Care+”) |
| 7 | ((MH “Patient Satisfaction+”) AND (MH “Nursing Care+”)) AND nursing patient relationship |
| 8 | TI Measuring Satisfaction |
| 9 | TI Improving Patient Satisfaction |
| 10 | Patient Satisfaction AND Nursing Role |
| 11 | Patient Satisfaction AND Nursing |
| 12 | Patient Satisfaction AND Nursing Satisfaction |
| 13 | Uncaring AND Nursing |
| 14 | Effects of nursing care on patient satisfaction |
Articles were included if the studies explored patient satisfaction in patient populations and measured patient satisfaction using standardized, validated instruments and were published in peer‐reviewed journals between 2000–2021 in English. The dates for inclusion were chosen to capture a significant change in how patient satisfaction was measured in the United States with the introduction of HCAHPS in 2006.
Studies were excluded if they were case reports, literature and systemic reviews, opinion/editorial articles or observational studies.
Each article was screened by title and abstract for the inclusion and exclusion criteria by the first author. Both authors screened articles that fit the criteria by full text. Disagreements whether to include articles were resolved by discussion and consensus between the authors. During this process the first author reviewed references of the considered articles for additional studies that fit the criteria. These articles were then subjected to review by both authors as above.
The quality assessment of the included studies followed two criteria, methodological or theoretical rigour and data relevance, on a 2‐point scale (high = 2, low = 1) (Whittemore & Knafl, 2005). No studies were excluded on the basis of quality; however, during the analysis, more weight was given to studies with rigour and data relevance rates of 2.
The purpose of this integrative review was to summarize the scientific literature on the elements essential to a nursing definition of patient satisfaction.
In this review, data were defined as results of studies that measured patient satisfaction; identified elements or factors that are not elements, of patient satisfaction; and written experiences of patient satisfaction. All studied elements were included if they had a significant relationship with patient satisfaction (p < .05) or if they were rejected. The exception to this was the one qualitative article included, where the authors' interpretations were reported.
Donabedian's conceptual model of assessing healthcare quality was used to organize the elements into the subcategories of structure, process and outcome (Donabedian, 1966). Kurowski and Shaughnessy (1982) posit patient characteristics can influence both process and outcomes for individuals. We modified Donabedian's model to include patient characteristics as a subcategory of patient satisfaction elements (Figure 1 ).
Donabedian's model modified to include patient characteristics
Elements in this review were defined as the essential components that create the complex concept of patient satisfaction. Each identified element was compared, and a determination was made if the elements were essentially the same or if there was enough uniqueness to categorized them separately.
The results of each study were entered into a data extraction tool and a coding index within Microsoft Word documents. The data extraction tool identified each article's research question, study design, setting, population, definition and components, measures used, intervention, results and the study's strengths and limitations. The first author organized the data into categories based on an extended Donabedian model. Both authors examined the data for patterns and relationships that might give a better understanding of the elements that make up patient satisfaction. Findings are the authors' interpretation of the data.
Because this review did not include human participants and only previously published research, no patient consent or ethical approval was sought.
Thirty articles were included in the analysis. Figure 2 presents the PRISMA flow sheet.
Of the 30 articles included for review, 13 reported on studies conducted exclusively in the United States. Two articles reported on studies that were conducted in both Norway and Turkey. France, Iran, Jordan, Malaysia, Netherlands, Poland, Slovenia, South Africa, Spain, Sweden and Taiwan were represented by one article each. One article reported on a study that included the United States and 12 European countries. Another article included five European countries.
Study designs varied in the selected articles, but most were cross‐sectional (n = 17). Other designs included prospective cohort studies (n = 4) and retrospective cohort studies (n = 3). Instrument development, randomized mode experiment, theoretical model testing, quasi‐experimental, descriptive comparative and qualitative study designs were all represented by one article. The reviewed articles overwhelmingly studied inpatient populations (n = 23), but outpatient settings were represented (n = 5), and two studies did not differentiate (Flood et al., 2016; Polak et al., 2019).
Five of the articles presented one or more definitions of patient satisfaction, yet none was original to the author (Table S1). The oldest definition found in the included literature was from 1975, and the most current definition from 2001.
Four of the five definitions describe patient satisfaction as a reaction to, or outcome of, an interaction between patients and healthcare providers (Findik et al., 2010; Larrabee, 2003; Mrayyan, 2006; Suhonen et al., 2012). Patient satisfaction, in these definitions, is a post‐care assessment. The fifth defines patient satisfaction as a measure of the current state of the relationship between healthcare providers and healthcare consumers (Ríos‐Risquez & García‐Izquierdo, 2016). That is, rather than a post‐care assessment of satisfaction, or an outcome, it is an in‐the‐middle‐of‐care assessment, identifying it as a process.
Twenty‐two instruments were used to measure patient satisfaction in the included articles. HCAHPS was used by six articles, Press Ganey satisfaction scores were used in three, and the Patient Perception of Hospital Experience with Nursing (PPHEN) was also used in three articles. No other instruments were used more than once (Table S2).
Nine of the 14 articles (64%) written in the United States used either HCAHPS or Press Ganey to measure patient satisfaction. Three articles written in the United States before HCAHPS was implemented (2006) used PPHEN (Dozier et al., 2001), Patient's Evaluation of Performance in California (PEP‐C) (Burns‐Bolton et al., 2003) or the Patients' Judgements of Nursing Care (Larrabee et al., 2004). The two articles written in the United States after 2006 that did not use HCAHPS or Press Ganey used an adaptation of the Army Provider Level Satisfaction Scale (APPLS) survey (Dragovich et al., 2017) and the Medical Expenditure Panel Survey Household Component (MEPS‐HC) (Chen et al., 2018). The PPHEN survey was used twice in articles from beyond the United States. Every other article used a different instrument to measure patient satisfaction.
Collectively, articles reported on 43 elements with a related to patient satisfaction and 25 element that were not related with patient satisfaction. Reported elements with significant relationships with patient satisfaction can be found in Table 2 . Elements without significant relationships with patient satisfaction are found in Table 3 .
Elements found to be related to patient satisfaction
