The Patient Satisfaction Concept: a Review and Reconceptualization

Jagdip Singh, Case Western Reserve University
ABSTRACT - This paper briefly reviews the current state of the literature concerning the patient satisfaction concept and proposes a reconceptualization of this concept to guide future research. Issues pertaining to the conceptualization, measurement and operationalization of the concept of patient satisfaction are reviewed. Based on this review, the paper calls for further development in this concept. More specifically, we argue that careful examination of questions along the lines of "what is the patient satisfied with?" in addition to "what is patient satisfaction?" can potentially afford greater insights into the focal phenomenon.
[ to cite ]:
Jagdip Singh (1989) ,"The Patient Satisfaction Concept: a Review and Reconceptualization", in NA - Advances in Consumer Research Volume 16, eds. Thomas K. Srull, Provo, UT : Association for Consumer Research, Pages: 176-179.

Advances in Consumer Research Volume 16, 1989      Pages 176-179


Jagdip Singh, Case Western Reserve University


This paper briefly reviews the current state of the literature concerning the patient satisfaction concept and proposes a reconceptualization of this concept to guide future research. Issues pertaining to the conceptualization, measurement and operationalization of the concept of patient satisfaction are reviewed. Based on this review, the paper calls for further development in this concept. More specifically, we argue that careful examination of questions along the lines of "what is the patient satisfied with?" in addition to "what is patient satisfaction?" can potentially afford greater insights into the focal phenomenon.

The purpose of this paper is to review the current state of the literature concerning the patient satisfaction concept, and to make a case for its reconceptualization. In particular, it is argued that for theoretical and empirical reasons it is appropriate to consider the notion that L;;e patient satisfaction concept is a construct with multiple foci. According to the view discussed here, patient satisfaction is the result of a process of evaluation (and comparison) of the service obtained from an object (e.g., a physician) in the patient's health care system. The specific contribution of the paper stems from the recognition that the health care system is not a homogeneous entity. Rather, it is composed of multiple objects or constituencies, such as the physician, the hospital, and the insurance provider. This approach may represent a natural evolution of the patient satisfaction construct from a concept concerned with evaluation of global satisfaction to a more specific formulation that specifies what particular object in the health care system serves as the focus of patient evaluations.

This paper is organized around three parts. First, we review the patient satisfaction literature from conceptual, taxonomical and empirical perspectives. Next, we build the case for multiple foci of patient satisfaction evaluations. Finally, we discuss implications of the proposed approach to future research into patient satisfaction.


Conceptual Issues

Hulka and her associates attempted to undertake the initial steps in the conceptualization of the patient satisfaction concept (Hulka, Zyzanski, Cassel and Thompson 1970; Zyzanski, Hulka and Cassel 1974). These researchers defined "satisfaction" as the patient's "attitudes toward physicians and medical care." (p. 430; Hulka et al. 1970). More specifically, a composite index of an individual's evaluative judgements concerning the quality of medical care received from physicians, nurses and other relevant sources is hypothesized to represent the individual's level of "satisfaction". Within the patient satisfaction literature, this conceptual definition has been widely accepted (Wolinsky 1976; Hines et al. 1977; Doyle and Ware 1977; Ware et al. 1918; Locker and Dunt 1978).

More recent research has challenged this conceptual definition from at least three perspectives The first perspective notes that the episode (or situation) is a major source of variation in "satisfaction" evaluations. Thus, it posits that patient satisfaction is better defined as an individual's evaluation of the quality of care in a specific medical-care situation; and not just as a global attitude aggregated across episodes. This argument is exemplified by a recent paper by Shore and Fran;;s (1986). These researchers note that individual patient-physician encounters are "she basic unit of medical care" (p. 580) and, therefore, assessing satisfaction for "individual encounters may contribute so a fuller understanding of the nature of physician-patient relationship" Similar arguments have been advanced by Inui and Carter (1985).

Second, researchers in the consumer satisfaction literature take issue with the definition of satisfaction as a cognitively based evaluation of product/service attributes. Instead, these researchers contend that satisfaction is an emotional or affective response to a product or service use (or consumption) situation (cf. Oliver 1981). This position does not imply that consumers (or patients) do not make cognitive evaluations. Rather, it distinguishes both, from conceptual and empirical standpoints, between cognitive and affective evaluations. More specifically, cognitive evaluations are treated within the framework of (disconfirmed) expectations. By contrast, affective evaluations are posited as a distinct concept which results from the preceding cognitive evaluations. However, patient satisfaction researchers have argued that attribute based "satisfaction" judgements are more appropriate because they allow a more richer measure of patients' satisfaction level and identifies areas (i.e., attributes) which contribute to satisfying or dissatisfying experiences.

Third, Ross et al. (1987) argue that restricting patient satisfaction to perceptions of the "quality" of health care received is an "inherent weakness." These researchers support their position by noting that a segment of "healthy but unhappy" patients has been found in several empirical studies. Thus, Ross et al. suggest that the conceptualization of the patient satisfaction should be enlarged to include other evaluations (e.g., waiting time, costs, etc.) in addition to purely quality perceptions. Hulka and Zyzanski (198^) acknowledge this position and a?pear to support a more broader domain for the patient satisfaction concept. In particular, Ware, Davies-Avery and Stewart (1978) have attempted to categorize the various health care evaluations into eight distinct "dimensions "

Operational Issues

Several researchers have attempted to develop operational measures for the patient satisfaction concept. Hulka, Zyzanski, Cassel and Thompson (1970) proposed one of the earliest operationalization's; a forty-two item measure for assessing the three dimensions of the patient satisfaction concept. Of the three dimensions, only the personal quality dimension had an alternate forms reliability greater than 0.7. For the professional competence and the access dimensions the reliability was 0.63 and 0.43 respectively. When different samples were utilized, similar levels of reliability were found by Hulka and her associates. In particular, the access dimension yielded consistently poor values for consistency of response.

Ware and Snyder 1975) proposed yet another operationalization for the patient satisfaction concept. The particular operational measure proposed had eight Likert items, and was conceptually designed to assess twenty-two dimensions of the satisfaction concept. Empirically, however, Ware and Snyder found support for four basic factors, namely, physician conduct, availability of service, continuity/convenience of care, and access to care.

More recently, Penchansky and Thomas (1981) provided an operational scale to measure the "access' component of satisfaction evaluations. These researchers posited that the access component itself is multi-dimensional. In particular, a sixteen item scale was proposed to measure five distinct dimensions, namely, availability, accessibility, accommodation, affordability, and acceptability. Using responses from a non-random sample of 287 respondents, Penchansky and Thomas found empirical evidence for the discriminant and construct validity of the proposed five dimensions of access.

Within the health care marketing literature, each of the preceding operationalizations have been utilized with some regularity. For instance, Tucker and Tucker (1985) report a study in which the operational measure proposed by Hulka et al. was incorporated. In a research to examine the sources of influence used in the selection of primary care providers, Sullivan (1984) utilized the operational measure proposed by Ware and his associates. Finally, an example of a study that used the Penchansky and Thomas scale is the research by Tucker and Tucker (1985).

In addition, some researchers have tended to develop their own measures of patient satisfaction. For instance, Scammon and Kennard (1983) attempted to assess respondent's evaluations of general and specific satisfaction using 26 seven point semantic differential items. Likewise, Andrus (1984) reports ten items used to measure consumer's satisfaction with the service that they received at the family practice office. Unlike the preceding three operationalizations, however, psychometric properties (e.g., reliability, factor analysis, discriminant/construct validity) for such indigenous scales are usually not available.


Two key points emerge from the preceding review of the patient satisfaction literature. First, considerable research attention has been directed toward the conceptualization and operationalization of the patient satisfaction concept. There appears to be growing consensus around the notion that patient satisfaction is a multi-dimensional (probably tripartite) evaluation of various aspects (quality and non-quality) of health care received in a specific episode. Second, much more research is needed to reconcile the diverse operationalizations and classifications schemas currently offered to conceptualize and measure patient satisfaction. What is needed is the systematic evaluation of the competing formulations so as to yield a generalizable, parsimonious, and empirically valid structure for patient satisfaction.

Although researchers have attempted to address questions along the lines of "What is patient satisfaction?", relatively less attention has been directed at issues such as "What is the patient satisfied with?" Consider, for instance, the eighty item measure ,proposed by Ware et al. Of the 80 items, 576 items pertain to satisfaction with a doctor, 4 utilize the hospital as the object of reference, another 4 concern medical insurance and the remaining 15 are general satisfaction items. By contrast, all of the 42 items in the Hulka et al. operationalization examine satisfaction with the doctor. Such inconsistencies underscore the importance of clearly identifying the object of evaluation inpatient satisfaction ratings.

It is a central thesis of this paper that patient satisfaction can be accurately understood as a collection of multiple satisfactions with various objects that comprise the health care system. In particular, we postulate that it would be useful for future research to: (a) identify the distinct objects (e.g., doctors, hospitals) that consumers perceive play a role in their health care; (b) operationalize the multi-dimensional concept of patient satisfaction at the level of the individual object; and (c) empirically examine the validity of this approach, that is, to investigate if satisfaction evaluations for the individual objects attain discriminant and construct validity.

Initially, at least three distinct objects that comprise the health care system can be identified; the physicians, the hospitals and the insurance providers. Organizationally, each of these objects represents a distinct constituency with its own goals and objectives. Although these objects work together to deliver medical care to individual patients, there is no guarantee that these constituencies have entirely common goals and objectives. For instance, the insurance provider may be interested in balancing the coverage with the premiums, the hospital in increasing the bed occupancy rate and the physician in the physical health of the patient. From the perspective of the patient, these objects also represents distinct individuals for interaction and communication. The patient probably interacts with an insurance agent in the process of obtaining health care, with the hospital nurses and administrators (e.g., for registration) for obtaining care from the hospital and with the physician himself/herself. These distinctions both, from an organizational and consumer interaction stand point, lend credence to the multi-object multi-dimensional conceptualization for the patient satisfaction concept.

Nevertheless, more rigorous analysis is necessary to properly evaluate the proposed conceptualization. If supported, it would offer several directions for future research. We now turn to these issues


A multi-object multi-dimensional perspective on patient satisfaction offers three main directions for future research. First, it posits that further development in the conceptualization and operationalization of the patient satisfaction concept is both, desirable and necessary. Issues that warrant the serious attention of researchers include: (a) identifying the distinct objects in the health care system; (b) resolving the inconsistencies in the classification schemas; (c) developing a taxonomical structure that is empirically valid; and (d) purifying (or enhancing) operational measures that assess the unique dimensions for each object. Considering the inherent complexity of the patient satisfaction concept, it seems desirable that such conceptual and measurement issues be addressed. This will facilitate better understanding of how patients evaluate the health care system. Such developmental work is also necessary if we are to understand why patients are satisfied (or dissatisfied) or what we can do to improve satisfaction levels. That is, our understanding of the sources and consequences of patient (dis)satisfaction would be more valid once issues pertaining to the conceptualization and measurement of the focal concept are satisfactorily addressed.

Second, the proposed conceptualization offers new avenues for investigation. Note much previous research has explored if patients are satisfied with their medical care. Instead of exploring such issues, the proposed conceptualization affords investigation of patient satisfaction levels with different objects in the health care system. Examples of such questions are: Are some patients more satisfied with their physicians than with their insurance providers? With what object are the patients most dissatisfied? Do the satisfaction levels for the various dimensions (i.e., expressive, instrumental and access) vary across objects (e.g., hospitals, physicians)? The presence of such differential perceptions raises new questions for further inquiry. That is, if such differential satisfaction levels indeed exist then explanations of such differences would entail investigations into the sources of patient satisfaction. In particular, sources (or causes) would need to be identified that not only explain why patients are satisfied but also why they are differentially satisfied with hospitals, physicians and insurance providers.

Finally, the multi-object perspective has the potential to offer more precise guidelines for managerial action. The measurement of the level of, and the object for satisfaction ratings allows targeting areas for more specific management programs to enhance customer satisfaction. Previous conceptualizations do not allow such precise targeting. For instance, the use of Ware et al.'s conceptualization may reveal that the major source of patient dissatisfaction is the "art of care", or in other words, the mode (not the content) in which the health care was delivered to the patient. It is clear that improving the mode of health care delivery would, in this hypothetical case, increase satisfaction. However, what is less clear is who should be the target for such changes? Should the nurses be trained to be more pleasant? or Should the physicians spend more time communicating with the patients? or Should the insurance agent be more customer oriented? The current operationalizations can not sort through these possibilities. By contrast, the proposed conceptualization for the patient satisfaction construct can address precisely such questions.


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