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Although the term ‗patient satisfaction‘ is widely used, it appears to be rarely understood (Sitzia & Wood, 1997), and there is little in the literature to operationally define the concept (Rofail, Gray, & Gournay, 2005; Williams, 1994). However, some commonly cited definitions view patient satisfaction as an emotional response and cognitive appraisal process of aspects of healthcare based on an individual‘s experience.

For example, patient satisfaction has been defined as an evaluation that involves ―a

comparison of the individual’s healthcare experience to a subjective standard‖ (Pascoe,

1983 p.189). Similarly, it has been suggested that to convey satisfaction or dissatisfaction is an ―attitudinal response‖ to patient‘s opinions about their clinical experiences (Kane, Maciejewski, & Finch, 1997 p. 715). Patient satisfaction has also been defined as ―affective” and “expressed as an attitude or feeling towards a product such as pleasure or

displeasure‖ (Ross, Frommelt, Hazelwood, & Chang, 1987 p. 22).

2.2.1 Patient Satisfaction with Healthcare

Satisfaction is a subjective rating and thus involves an individual‘s evaluation of particular aspects of care (Ware, Snyder, Wright, & Davies, 1983). These include interpersonal aspects (features of interaction between healthcare provider and individual receiving services, for example, respect and friendliness), technical quality (competence of healthcare providers and adherence to standards for diagnosis and treatment), accessibility/convenience (factors that impact receiving medical care), continuity (maintaining consistency with regard to the healthcare provider or location of care received), physical setting (such as how pleasant the atmosphere is), financial considerations (factors related to paying for medical services), and efficacy (the results of medical care) (Ware et al., 1983).

Patient satisfaction with health care has also been defined as ―the individual’s

positive evaluations of distinct dimensions of health care‖ (Linder-Pelz, 1982 p. 580).

Linder-Pelz‘s definition posits that patient satisfaction is a uni-dimensional concept (a single concept) composed of five social-psychological determinants: 1) occurrences (what actually happens, or the individual‘s perception of what occurred); 2) value (evaluating the health care experience); 3) expectations (beliefs regarding the likelihood that certain attributes are linked with an event, and the anticipated outcome of that association); 4)

interpersonal encounters (an individual‘s rating of healthcare experience compared to all other similar encounters); and 5) entitlement (the belief that one has proper grounds for seeking/claiming a particular outcome) (Linder-Pelz, 1982). Sitzia and Wood (1997) refined this model further by moving interpersonal encounters and entitlement under the expectations heading. Further, whilst patient expectations, values, and perceived occurrences were independently associated with patient satisfaction, these variables explained less than 10% of the total variance of patient satisfaction (Jackson, Chamberlin, & Kroenke, 2001) (see section 2.6 for potential covariates of patient satisfaction).

Instead of a uni-dimensional concept, Fitzpatrick (1984) proposed three independent models of satisfaction – the need for the familiar, the goals of help seeking and the importance of emotional need – each associated with one determinant. ―The need

for the familiar‖ states that social expectations (such as cultural differences) determine the

degree of satisfaction. However, a review by Sitzia & Wood (1997) suggested findings were ambiguous (e.g. Jain et al., 1985; Madhok, Bhopal, & Ramaiah, 1992). Closer examination of the studies they cited suggests that the association between cultural differences and satisfaction is not so clear. For example, the Jain et al. study (1985) cited by Sitza and Wood that explored attitudes of Asian patients to the delivery of healthcare in GP settings suggested that the doctor‘s nationality may be important to some patients. However, the results were problematic in that the question asked to assess satisfaction (‗have you thought of leaving your present doctor‘) may not have sufficiently addressed the issue, and these findings cannot be used as conclusive evidence of an association between cultural differences and satisfaction.

―The goals of help seeking‖ model suggests satisfaction is not the main focus for individuals; instead, they seek a solution to their health problems (Fitzpatrick, 1984). However, anecdotal evidence suggests that individuals with good health status may be

unhappy or dissatisfied, and individuals with poor health status may be happy or satisfied (Ross et al., 1987). Further, because patients‘ perceptions about change in health status are not usually measured in satisfaction studies (Wensing, Grol, & Smits, 1994), it‘s difficult to assess the adequacy of the model.

―The importance of emotional need‖ is the third model and is based on the emotional experience that individuals have both because of uncertainty and anxiety due to health problems, as well as the fact that many individuals are only able to assess healthcare professionals‘ competency from a non-technical perspective. Consequently, this model proposes that individuals judge satisfaction according to affective behaviour and communication skills. According to Sitzia and Wood (1997) evidence for this model seems to have emerged in part from Ben-Sira‘s work (1976), in which satisfaction with treatment from GPs was strongly related to perceptions of interest and devotion from the doctor rather than technical skills or administrative aspects (Ben-Sira, 1976).

Whilst it is apparent that there have been several attempts to define patient satisfaction, the definitions are relatively vague and thus the question of what actually constitutes patient satisfaction remains unanswered. Further, the above definitions relate to patient satisfaction with healthcare, or aspects of healthcare rather than specific to treatment (see section 2.2.2).

2.2.2 Treatment Satisfaction

Though there are few definitions of patient satisfaction with treatment, it can be defined operationally, as in terms of antipsychotic medication: ―Treatment acceptability

(positive orientations towards treatment) and medication insight (self knowledge, awareness, and understanding) into the need for medication and its potential side effects‖

(Rofail et al., 2005 p. 1068). The operational definition can be reliably and validly measured using the Satisfaction With Antipsychotic Medication (SWAM) scale (Rofail et

al., 2005). For example, an advisory team agreed that the content of the SWAM scale was relevant and important to patient satisfaction with antipsychotic medication, and that the scale demonstrated clear face validity. In addition, a number of HCPs who reviewed the questionnaire felt that it was useful. The SWAM scale contains two scales, Treatment Acceptability and Medication Insight. Both have good internal consistency with Cronbach‘s alpha of 0.92 and 0.84 respectively.