Over the past 10 years there has been increasing interest in “consumer satisfaction” in the NHS, starting with the Patients’ Charter of 1991, and culminating with the NHS Plan.¹

The essence of the NHS Plan is to make patients’ views and interests the driving force behind reform. Among the core principles of the plan is the statement that “quality will not just be restricted to clinical aspects of care, but include ... the entire patient experience”. To show that the service is responding to patient priorities, every NHS organisation is now required to publish an annual account of the views received from patients, and the action taken as a result.²

Few clinicians would disagree with the idea that improving patient satisfaction is a desirable end in itself. Related benefits may include improved morale and job satisfaction in emergency department (ED) staff, a reduced tendency for patients to seek further opinions, and a reduced incidence of complaints and litigation. There is also evidence of improved patient compliance.^3,4 Improved satisfaction in EDs is likely to have a significant impact on the public view of hospital and emergency care in general.

The aim of this systematic review was to identify the published evidence relating to patient satisfaction in emergency medicine, thereby providing useful information for clinicians, and helping to guide future strategies for assessment and improvement in this area.

METHODS

A literature search was carried out using the WebSPIRS from SilverPlatter interface, accessed via the SWICE gateway. The Medline, CINAHL, EMBASE, ASSIA, and HMIC databases were searched from January 1990 to January 2002, using the terms [PATIENT-SATISFACTION and (“Emergency Department” or “Accident and Emergency” or “Casualty” (TW))].

Papers of potential relevance were retrieved, and their reference lists searched for additional relevant material. This process was repeated until no new information was found.

Reviewed papers were grouped under two headings:

1. Research to identify and rank factors influencing overall satisfaction in ED patients.

2. Intervention studies attempting to improve patient satisfaction in the ED.

RESULTS

The initial computerised database search identified 583 papers of potential relevance. Many papers were found that included measures of patient satisfaction “tagged on” to a clinical intervention study, but these tended to show the acceptability of the intervention, rather than its effect on satisfaction. Such studies were therefore excluded.

The studies reviewed were too heterogeneous for formal meta-analysis. Nevertheless, the following key points emerged:

Choosing factors to assess

Most papers assessed a variety of service factors, process of care measures, or patient related factors chosen from the literature, staff opinions, or ad hoc by the authors.

The most frequently assessed service factors in emergency medicine were: perceived and actual waiting times; explanations/information on multiple aspects of process and treatment; staff attitudes; ED environment; perceived standards of technical care. Table 1 lists the factors assessed in individual studies, the assessments used, and a summary of the main findings.

Patient factors that influence satisfaction

Most studies collected data on some “background variables”, such as age, sex, social status, ethnicity, and severity of illness. Age and race influenced satisfaction in some studies,^5,6 but not all.⁷ Triage category was strongly correlated with satisfaction,^5,6,8 although this could be viewed as another indicator of the waiting time.

Inclusion and exclusion criteria varied enormously between studies, and in some were unspecified. The “point of view paradox” dictates that as the severity of illness increases so patient expectations regarding non-clinical service factors decrease,⁹ so it is important to be aware of the population in which satisfaction is being measured.

Apart from Morgan et al’s survey of Sheffield residents,¹⁰ multicentre studies by Hall⁷ and Sun,⁵ and Yarnold’s comparison of an academic and community ED,¹¹ most papers reported single centre studies. Table 2 shows the different survey methods, populations, and response rates. A few papers sampled the population in the form of a “census”—that is, they attempted to enlist every patient within the study population over the study period. Others used population sampling, either random, systematic, or by quota.

Service factors that influence satisfaction

Three broad headings cover the most commonly identified areas of importance. These are “interpersonal skills/perceived staff attitudes”,^7,10–13 “provision of information/explanation”,^5,7,13–18 and “aspects related to waiting times”, particularly the perceived waiting time in relation to the patient’s expectation.^{7,8,10,12–14,17–19} The relative ranking of specific service factors in relation to global satisfaction remains unresolved.

Intervention studies

In total, seven controlled trials that studied satisfaction as a primary outcome measure were found, with two of these from the UK. Three assessed whether the provision of general information to patients on their arrival influenced overall satisfaction.^20–22 Two of these related to written information, and one to an informational video. All three demonstrated improved satisfaction, as well as an improvement in the perception of other service factors, in the informed groups.

Two studies report improved patient satisfaction as a result of staff training. In one paper all ED staff underwent “customer service training”,²³ while in the other doctors attended a communication skills workshop.²⁴

The two UK papers focus on nurse triage,²⁵ and an emergency nurse practitioner (ENP) service.²⁶ Nurse triage had little effect on patient satisfaction, but a comparison between traditional ED and ENP care showed that ENP care led to improved satisfaction with some communication related service factors.

DISCUSSION

Many problems are inherent in the analysis of satisfaction in ED patients. Firstly, “satisfaction” is not easy to define, secondly, methods of quantifying and qualifying satisfaction are still emerging in emergency medicine, and thirdly, emergency physicians care for the largest and most diverse patient population.

Quantifying “satisfaction”

Studies aiming to correlate specific factors with “overall satisfaction” have chosen various tools with which to measure global and factor satisfaction. Techniques range from using simple questions with dichotomous answers, to non-directive interviewing techniques where “main themes” are identified. Direct questions using the word “satisfaction” have been used, or overall satisfaction is extrapolated from indirect questions such as “willingness to recommend” or “willingness to return”.^5,12 Combined factor satisfaction scores have also been used to predict overall satisfaction,¹⁵ although this approach has been questioned.⁸

Questionnaire validity is difficult to assess, as there is no “gold standard” for patient satisfaction. However, in some studies patient views have been “validated” against independent measures of doctors’ interpersonal skills, communication styles, and technical proficiency.²⁷

Response rates

Adequate survey response rates are a challenge to achieve, and vital for results to be meaningful. Response rates will be increased by “on the spot” surveys in the ED, although late night attendees have often been excluded by studies using convenience sampling. If surveys are conducted after the patient has left the ED, bias can be introduced by the delay, and responses tend to be more positive if the acute problem has resolved.²⁸ Few studies to date have been longitudinal, assessing changes in attitude over time,¹⁵ although a small number make more than one approach to the respondent.⁵

Many ED patients are not competent to respond. Some surveys therefore include “accompanying person” respondents or, when the study population includes children, parent/guardian respondents.^{11,13,16–19} Reported satisfaction levels in these situations are likely to be influenced by the factors most affecting the proxy respondent, for example, waiting times, facilities, communication, and access to the patient.

Future directions

The complexities of the relation between separate care factors and global satisfaction mean that local intervention studies will be unlikely to show striking improvements in overall satisfaction. Nevertheless, the existing literature does indicate which areas to concentrate on, and which approaches to use, in future research studies.

To assess the impact of specific interventions, and changes over time, a baseline must first be established. Methodologies for assessing patient satisfaction, both with individual service factors and the overall emergency department experience, are now becoming more thoroughly developed and refined. The most commonly used tool is a Likert scale, which offers a range of choices from strongly positive to strongly negative. Because patient responses are biased towards positive choices many researchers have used “asymmetrical” or “weighted” scales to overcome this.²⁷ The number of points on the scales varies within and between papers, but it has been shown that scales with more than five responses do not carry significant advantages.²⁷ Visual analogue scales are also popular, and give comparable results to Likert scales.²⁷ Some authors have recently proposed other methods for satisfaction assessment.^5,28

Focus groups may be used to identify key issues of patient concern. Data collected from such groups have been compared with government assumptions of what patients want,¹⁴ and used to validate questionnaire design.²⁹ A review of complaints (and compliments) will also provide qualitative information that may be very useful at a local level.

Previous research indicates that three interventions worthy of further study are:

1. Improving interpersonal, attitudinal and communication skills in ED staff. There is evidence that a short training course may be highly effective in this regard.^23,24

2. Provision of more information and explanation.

3. Reduction of the perceived waiting time.

The last is currently receiving considerable government attention in the UK,³⁰ with the anticipation that waiting times will fall and, presumably, patient satisfaction will improve. Future research could usefully study the effect of this and similar interventions in the ED, as well as clarifying the relative importance of the main service factors identified.

The preferred methodological approach to future intervention studies will depend upon local circumstances and the factor(s) under study. Over the past 10 years the design and interpretation of satisfaction studies has become increasingly sophisticated. Interest in qualitative, rather than quantitative, research methods is growing, and some recent studies have combined the two approaches in an attempt to develop more reliable and valid tools for measuring satisfaction.^10,29 Multi-centre studies are generally preferable, because of their inmproved external validity, but very few have been reported to date. For some factors (such as patient information) a randomised design is feasible, but for other interventions (such as reductions in the perceived waiting time) alternative or novel approaches may be required.

CONCLUSIONS

To a great extent, patients must trust their clinicians to continuously review and improve their clinical and technical skills. The emphasis now placed on evidence based practice recognises this responsibility. However, in the quest to improve the science of medicine, medicine as an art may be suffering. The balance will be somewhat restored if we succeed in identifying, and responding to, wider patient needs. The study of patient satisfaction is a step in this direction.

Research to date has identified which broad aspects of the service our patients care most about. There are many potential interventions that could be tailored to local needs, and the papers already published can usefully inform future strategies for assessing and improving patient satisfaction in emergency medicine. We will never please “all of the people all of the time”, but within our own departments we can now start investigating measures that will please more of our patients most of the time.