literature review on patient care

• Research article
• Open access
• Published: 11 June 2020

Patient feedback to improve quality of patient-centred care in public hospitals: a systematic review of the evidence

• Eunice Wong   ORCID: orcid.org/0000-0001-9274-7547 1 , 2 ,
• Felix Mavondo 3 &
• Jane Fisher 2  

BMC Health Services Research volume  20 , Article number:  530 ( 2020 ) Cite this article

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To review systematically the published literature relating to interventions informed by patient feedback for improvement to quality of care in hospital settings.

A systematic search was performed in the CINAHL, EMBASE, PsyInfo, MEDLINE, Cochrane Libraries, SCOPUS and Web of Science databases for English-language publications from January 2008 till October 2018 using a combination of MeSH-terms and keywords related to patient feedback, quality of health care, patient-centred care, program evaluation and public hospitals. The quality appraisal of the studies was conducted with the MMAT and the review protocol was published on PROSPERO. Narrative synthesis was used for evaluation of the effectiveness of the interventions on patient-centred quality of care.

Twenty papers reporting 20 studies met the inclusion criteria, of these, there was one cluster RCT, three before and after studies, four cross-sectional studies and 12 organisational case studies. In the quality appraisal, 11 studies were rated low, five medium and only two of high methodological quality. Two studies could not be appraised because insufficient information was provided. The papers reported on interventions to improve communication with patients, professional practices in continuity of care and care transitions, responsiveness to patients, patient education, the physical hospital environment, use of patient feedback by staff and on quality improvement projects. However, quantitative outcomes were only provided for interventions in the areas of communication, professional practices in continuity of care and care transitions and responsiveness to patients. Multi-component interventions which targeted both individual and organisational levels were more effective than single interventions. Outcome measures reported in the studies were patient experiences across various diverse dimensions including, communication, responsiveness, coordination of and access to care, or patient satisfaction with waiting times, physical environment and staff courtesy.

Overall, it was found that there is limited evidence on the effectiveness of interventions, because few have been tested in well-designed trials, very few papers described the theoretical basis on which the intervention had been developed. Further research is needed to understand the choice and mechanism of action of the interventions used to improve patient experience.

Peer Review reports

Public health services have been moving towards putting patients at the centre of their care. Patient-centred care is defined as ‘care that is respectful of and responsive to individual patient preferences, needs and values, and ensuring that the patient’s values guide all clinical decisions [ 1 ]. Patient-centred care is considered to be one of the six domains of quality of care, where listening to and seeking to understand patients’ perspectives of their needs, is key to the delivery of good quality care [ 1 ]. For greater clarity, the relationship between quality of care and patient-centred care is illustrated in Fig.  1 .

The relationship between quality of care and patient-centred care

This approach to care (Fig.  1 ) promotes respect for patients’ preferences and values, and provision of emotional support, physical comfort, information, communication and education, continuity and transition of care, coordination of care, access to care and the involvement of family and friends [ 2 , 3 , 4 ]. These have been shown to be associated with clinical benefits [ 5 , 6 , 7 , 8 ] and healthcare cost reductions [ 9 , 10 , 11 ].

Patient-centred care is assessed by patient feedback of their experience often referred to as patient experience measures [ 8 ]. It is becoming common for these measures to be collected routinely in order to monitor patient-centred care [ 12 , 13 , 14 ] . The U.S. and U.K., were among the first to develop and implement nationally standardised surveys for measuring patients’ experiences. The American CAHPS (Consumer Assessment of Healthcare Providers and Systems) surveys were developed in 2008 and implemented in 2011. In the U.K., the reporting of the results of national standardised survey of NHS patients was made mandatory in their national health policy in 2010 [ 11 , 15 ]. Other countries such as Australia, Canada, Denmark, the Netherlands also established systems for collecting patient experience measures under their health policies, in their efforts to improve patient-centred care and other domains of quality of care [ 12 , 13 , 14 ].

Although the various methods of collecting patient experience such as complaints, compliments, surveys, interviews and focus groups have been widely researched [ 16 , 17 ], there is still a debate about the use of the terms ‘satisfaction’ and ‘experience’ in these measures, which are sometimes used interchangeably [ 18 , 19 ]. Traditionally, up to the 1990s, patient satisfaction surveys were used to measure the quality of care from patients’ perspective. However there were theoretical arguments against its sensitivity and usefulness, as ‘satisfaction’ was conceptualised as people’s expectations and appraisals of care and not the actual ‘experience’ which relates to things that happened during care [ 19 ]. This led to the development of new patient experience surveys in the 2000s where the emphasis is on what happened to the patients during their hospital stay or clinic visit.

A recent systematic review [ 20 ], on the collection of patient experience and its use for quality improvements in health services, found that most quality improvement areas were in processes for admissions and producing patient education materials. Notably, these findings focused on areas that do not require changes to healthcare professionals’ behaviour, yet many components of the patient experience are integral to the interactions, patients have with healthcare professionals.

Moreover, findings (results) from patient experience surveys frequently highlight the lack of time in consultations, difficulties in understanding tests and information from doctors and lack of details and specificity from the survey needed for quality improvements [ 21 , 22 , 23 , 24 ]. The lack of patient involvement in developing quality improvement initiatives, the insufficient expertise by healthcare professionals in conducting improvement work and lack of time and resources were some of the key barriers to efforts to improve quality of care [ 7 , 20 , 25 ].

Understanding which interventions are effective in improving the various dimensions of patient-centred care is needed to achieve good quality care. Improvement efforts in health services cannot be made without the feedback of patients, participation or changes on the part of the healthcare professionals and the resources and support of their organisations [ 26 , 27 ]. At present, it is unclear which interventions are effective and which behaviours need to change on the part of healthcare professionals and their organisations. The aim was to review the evidence about the impact of interventions informed by patient feedback on quality improvements in patient-centred care in hospital settings.

Search strategies

The research adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) 2009 checklist [ 28 ] and the review protocol was published (PROSPERO:CRD42018112964). The CINAHL, EMBASE, PsyInfo, MEDLINE, Cochrane Libraries, SCOPUS and Web of Science electronic databases were searched. Search terms included a combination of keywords, MeSH-terms and text words related to feedback OR patient satisfaction OR patient preference AND quality of health care OR outcome and process assessment (healthcare) OR outcome assessment (healthcare) OR treatment outcome OR process assessment (healthcare) OR program evaluation OR quality assurance, health care OR quality improvement OR quality indicators, healthcare OR standard of care OR patient safety OR patient-centred care OR healthcare quality OR quality of service OR health outcome AND hospital, public were entered. The search was limited to published studies from January 2008 as the literature documented the development of patient experience surveys in U.S. in 2008 and the reporting of standardised patient experience survey results in other countries from 2010.

Study selection

Inclusion and exclusion criteria.

Studies were included if they had investigated an adult population, reported feedback from patients and quality improvements to care, published in an English peer-reviewed journal from January 2008 till October 2018.

Using a standard form, information on study design, study setting, sample characteristics, sources of patient feedback, details of interventions used and outcomes were extracted by one author (EW) and verified by another author (JF). Where there was disagreement the third author (FM) reconciled the decision.

Assessment of study quality

The Mixed Methods Appraisal Tool (MMAT) [ 29 ] was used to assess study quality. The MMAT includes specific criteria for mixed methods studies, as well as for qualitative and quantitative studies. In MMAT revised (2018), the authors discouraged the use of an overall numerical score to reflect the quality of the studies but to provide a detailed presentation of the ratings of the criteria to reflect the quality of the included studies [ 30 ]. The assessment is made against five criteria, scored as ‘Yes,’ ‘No’ or ‘Can’t tell’, and it was developed systematically [ 31 ]. For ease of discussion, in this review the studies were ranked as high (all criteria met), medium (four out of five criteria met) and low (three or less criteria met).

Data synthesis and analysis

Data synthesis allows researchers to critique and integrate research data from diverse disciplinary perspectives and studies which have used qualitative, quantitative, and mixed designs. Studies with multiple components intervention were coded to each of the intervention areas identified and according to the quality of the study; leading to some being counted more than once in the summary table. This approach is recommended for reviews seeking to understand the effectiveness of certain intervention areas, by categorising interventions by commonalities rather than considering the multiple components intervention as a whole unit [ 32 , 33 ]. Finally, a narrative synthesis was used to report the evaluation of the studies.

Search results

The initial search returned 1746 papers (Fig.  2 ), which were imported to Endnote and subsequently to Covidence [ 34 ] for screening; after removing duplicates, 1232 papers were retained. The title and abstracts were screened against the inclusion criteria. Two authors (EW and JF or EW and FM) assessed the papers and yielded 28 papers for inclusion. The final retention of 20 papers were made by consensus, any disagreements were resolved by consensus or consultation with a third author (FM or JF). The main reason for exclusion at this stage was that papers mentioned inclusion of patient feedback in the abstract but did not give any details of the patient feedback collected.

PRISMA flowchart showing the selection of studies

Quality assessment

Assessment of studies using MMAT indicated that two studies rated high fulfilling all five criteria, five studies rated medium meeting four criteria, 11 studies met only three or fewer criteria were rated as low and two studies could not be appraised because details regarding research aims, data collection methods or analysis were not provided (See Additional file  1 ).

Methodological characteristics and main findings

All studies included in the final review were based in hospital settings, and of these, three also included the health services’ primary and community care settings as they formed part of the organisation. The methodological characteristics and main findings are summarised in Table  1 .

Study location, sample and design

The studies were conducted in eight countries, UK ( n  = 6), Australia ( n  = 3), US (n = 3), the Netherlands ( n  = 2), Taiwan ( n  = 2), Canada ( n  = 1), Italy ( n  = 1), South Africa ( n  = 1) and the United Arab Emirates ( n  = 1). The different sources of feedback in the studies were interviews ( n  = 7), patient experience surveys ( n  = 6), patients’ narratives of their experience ( n  = 2), complaints ( n  = 2), patients’ perception of service quality ( n  = 1), patient views on access ( n  = 1) and patient ratings online of hospitals ( n  = 1).

A total of 77,588 participants contributed data to 17 studies, and participants characteristics were not reported in three [ 46 , 53 , 54 ]. The 20 studies were conducted in inpatient or outpatient settings in public hospitals with five studies providing additional details on the speciality settings. They included specialised cancer treatment ( n  = 3) and emergency medicine ( n  = 2).

The 20 studies comprised a cluster randomised control trial ( n  = 1), before and after studies ( n  = 3), cross-sectional studies ( n  = 4), and organisational case studies ( n  = 12). The outcome measures in all the studies were on patient experience or patient satisfaction with waiting times, physical environment and courtesy of staff, which are components of the patient experience.

Intervention

Areas of interventions.

The interventions proposed and implemented in the studies were synthesized according to the target area of the interventions. Multi-component interventions targeting more than one area are accounted for in each of their target area of intervention, to provide a comprehensive view of intervention areas. Further details on the nature and examples of interventions in the areas of communication with patients, professional practices, clinicians’ responsiveness to patients, patient education, the physical hospital environment, quality improvements, and improving the use of feedback are provided in Table  2 . Only one of the studies [ 40 ] reported their theoretical basis and four studies [ 50 , 51 , 54 , 55 ] specified the use of quality improvement and experience-based co-design methodology.

Communication

Interpersonal communications about health conditions and care transitions between patients and staff were the key area of intervention identified in improving patient experience in the studies in this review. The interventions targeted changes in staff’s communication behaviours, for example, provision of weekly education sessions on communication skills and setting behavioural targets for staff. The frequency and mode of delivery of the education sessions reported were varied but they shared similar education content on customer service and interpersonal communication skills [ 36 , 37 , 38 ]. However, significant increase in satisfaction with explanation given and courtesy and efficiency of staff was only reported in Harnett et al.’s study [ 36 ] where the education component is part of a suite of other interventions.

In addition to staff education, two studies [ 37 , 38 ] also reported on organisational level interventions as part of the suite of intervention. Aboumater et al. [ 37 ] observed that hospitals with high patient experience scores promoted specific behaviours on communication and engagement of patients to staff using acronyms and slogans on (65%) and set standards and targets for staff for patient-centre and excellent service (60%). This observation is also noted by Buurman and colleagues [ 38 ] in their study where targets were set for staff, adoption rates of personalised communication with patients on discharge increased by 20% over 3 years. However, these changes cannot be assumed to be related to the interventions in the absence of a control group, in their study designs, it could be attributed to the passage of time or other factors.

Two further studies [ 51 , 55 ] used experience-based co-design as an approach to engage, seek patient feedback on their experiences and views to identify improvements, discuss, design a suite of changes in communication, and professional practices. As the experience-based co-design methodology in its nature is about tailoring to the context, the findings from these studies may be limited to the experience of patients accessing cancer treatment services and emergency departments of hospitals. There was no measurement of patient experience, but the patients reported having had good experience when interviewed about the effects of the changes.

Professional practices in continuity of care and care transitions

Four studies highlighted discharge planning and associated care processes such as follow-up phone contact, giving written discharge information to patients as a focus area in improving patient experience. It was found in two studies that use of both individual and organisational level interventions was significantly more likely to have a difference in patient experience. Aboumater and colleagues [ 37 ] reported that 52–56% of hospitals with high patient experience survey scores, indicative of high quality hospitalisation experience in their study, implemented multi-disciplinary rounds, follow-up with patients via phone calls post-discharge by nurses and used discharge folders for information sharing and consolidation. Organisational level interventions of using templates for personalised discharge letters, incorporating personalised discharge letters into the computer system of electronic medical records and integration of its use as hospital-wide policy were associated with an increase in the use of personalised discharge letter from 30 to 50% in the hospital over a 3 year period in Buurman et al.’s study [ 38 ]. Furthermore, two case studies [ 51 , 55 ] that provided an in-depth understanding of the experience-based co-design approach supports this observation between intervention to care processes and good patient experience. These studies explore the experience-based co-design approach in the redesign of palliative care and cancer care processes as part of a suite of interventions, where good experience was reported by interviewed patients.

Responsiveness to patient

The role of nurses was highlighted as a common component of the interventions employed in three studies [ 37 , 41 , 48 ], to improve the patient experience. The interventions targeted behaviours that were perceived by patients as respectful, courteous, prompt and person-centred. However, only weak associations between these interventions and positive patient experience were reported. In Abounmater et al. which used proactive nursing rounds (83%), and executives and leaders making rounds to engage and respond to patients (62%) [ 37 ], had high patient experience scores. Richard et al.’s cross-sectional study [ 41 ] observed that patients with nurse navigator support compared to those without reported higher satisfaction with waiting times.

The role of doctors was generally not explored with the exception of Madden and Davis’ study [ 42 ] where secondary data analysis was conducted to compare the results of two national patient experience surveys conducted in 2000 and 2004. It is interesting to note that this is the only study that reported a downward trend in aspects of patient experience with doctors (confidence in doctor and understanding of tests from doctors’ explanation) for patients using breast cancer services in three health services. This was in spite of reported upward trend on a national level (across 172 health trusts in UK). The influences on this downtrend trend is unknown as there were no reported investigation on the probable causes or associations.

Patient education

Conceptualisation of patient education differed among studies. In Reeves and Seccombe’s study [ 43 ], patients were given a comprehensive patient information pack about the discharge processes. This intervention was further complemented with the organisational level intervention of inclusion of its implementation action plans as part of staff performance assessment. While two other studies [ 42 , 50 ] did not provide details and defined it as information for patients. There was no significant evidence on any association or efficacy of interventions in this area from these studies.

The physical environment

Interventions to improve the physical environment found in two studies, focused on engaging patients in the redesign of physical spaces in the emergency department [ 50 ] and reduction of noise levels in the hospital [ 43 ]. Overall, the changes in the physical environment could not be solely associated with changes to the patient experience, as these interventions were part of a larger suite of interventions.

Improve use of feedback

Reeves and West’s study was the only cluster RCT [ 35 ] in this review. They found significantly better experience survey scores among patients in the condition where wards held facilitated meetings to review patient feedback and plan improvements compared to the two other conditions (feedback sent to the Matron of ward and feedback on ward level sent to individual nurses). From the findings of the study, the authors hypothesised that it is the opportunity for facilitated delivery of the feedback to nurses that increased the acceptability of the feedback that prompted the change in behaviour.

• Quality improvement

The studies [ 43 , 48 ] that investigated interventions used in quality improvement projects suggested that it is necessary to approach this at both the staff and organisational levels. They observed that good patient experience was possible when there was regular data review, effective implementation of action plans, and incentives and staff performance review by their organisations.

The results of this review show that interventions employed in the included studies, predominantly target and support the theoretical dimensions of patient-centred care. Interpersonal communication between healthcare professionals and patients about their health conditions and care, processes affecting care continuity and discharge planning and showing respect for patient preferences and providing emotional support clearly emerged as important intervention areas, most frequently noted in the 20 studies. However, the efficacy of the interventions must be interpreted with caution because causal relationships were mostly not tested in the studies included in this review.

Strengths and limitations

The strength of this review is the specific focus and inclusion of the use of patient feedback for improving patient-centred care in the search strategy for the review. The search strategy was designed in consultation with an information analyst, to produce a replicable search for all relevant multiple databases, using MeSH search terms and the inclusion of all study designs, single and multiple interventions and variety of countries, to provide a search of the evidence that has been applied to the existing context in health services rather than just research settings.

We acknowledged some limitations in this review, only studies published in English language and after January 2008 were included. There could be other relevant studies published prior and in other languages that were missed. Further details on the interventions in the included studies could also be missed as no further contact was made with their respective authors.

Main findings

There are several possible explanations for this weak body of evidence on the efficacy of the various interventions, firstly, the study designs employed in the studies were mainly correlational and qualitative and secondly, the quality of the studies. There is only one cluster RCT in this review that provided evidence that patient feedback was effective in improving quality of care when it was facilitated and discussed with nurses and planned for at ward level compared to other conditions where it was not facilitated or discussed. Overall, 11 studies reported improvement in patient experience outcomes, but only five studies quantified their findings by reporting on the changes in outcome measures.

The quality of evidence of the five quantitative studies that reported outcome measures was low, beyond the limited representativeness of the study populations in some of the studies, the weak associations between the interventions and outcomes with no acknowledgment of potential confounders such as the passage of time.

The qualitative studies in this review were more varied in study quality, four of the studies were conducted well with detailed reporting. The studies highlighted how experience-based co-design methodology was utilised in acute care settings to engage and partner patients in making improvements to care and also contribute to the understanding of the areas of care that were deemed important by patients.

Studies that used multiple interventions targeting change on both individual and organisational levels were associated with better outcomes than those studies with single interventions. This review found that interpersonal communication training for healthcare professionals combined with organisational policies of setting targets and promoting behavioural standards for the staff were associated with improved (increased) patient experience. Similarly, this association was also found with implementing processes and practices with multidisciplinary team meetings and sharing of discharge information practices, in conjunction with organisational policies of setting targets and promoting behavioural standards for the staff.

These findings are in line with studies [ 56 , 57 ] that explored a system view in implementing interventions where considerations are given to mediating factors organised by structure (organisational characteristics), process (care processes) and outcome (patient experience, clinical outcomes) using Donabedian’s model. This is further supported by findings from studies [ 58 , 59 ] investigating factors needed for successful implementation and integration of interventions to routine work using the Normalisation Process Theory [ 60 , 61 ]. With the acknowledgement of targeting change on multiple levels within a system, it is not surprising that there is a growing body of literature on developing and evaluating multiple components interventions [ 62 ].

Beyond the limitations of the study designs and quality of the studies, a plausible explanation for the weak evidence is the lack of explicit use of theory in the intervention development or discussion of results in the majority of the studies. The importance of using theory is reflected in the growing research of using behavioural and organisational theories in the design of interventions involving professional practice and the understanding of which mechanism or elements of the interventions are the most important [ 63 ]. For example, in the studies targeting improving communications between patients and healthcare professionals, the effective interventions were using a combination of educational sessions for staff and action planning and monitoring interventions by organisations. Without being explicit about their theory of change, in the communication behaviours in those studies, it is plausible that educational sessions for staff were conducted to engage staff on communication as a priority, instead of their lack of skills. If that was true, more targeted interventions to address engagement and prioritisation by healthcare professionals could be more effective.

There are different theories that may be relevant for developing interventions at multiple levels, using approaches that address, cognitive, educational and organisational theories that can contribute to changing healthcare professionals’ behaviours [ 64 ]. For example, theories such as theory of planned behaviour and social learning theory [ 65 , 66 , 67 ] may be more relevant to interventions directed at individuals and teams. On the other hand, organisational theories such as Continuous Quality Improvement [ 68 ] and organisational quality culture [ 69 ] may be more relevant to interventions directed at service redesign for the whole hospital with multiple stakeholders [ 63 ].

Further research

From the review findings, the field of research could explore the gap in the explicit use of theory in their target for change and choice of interventions. This will enable the comparison of interventions and their mechanism of action, across settings to build the evidence base. Beyond those interventions found in this review, another gap to address is the lack of research in the interventions targeting the emotional support, access to care, involvement of family and friends dimensions of patient-centred care. It could provide further insights in the interpersonal relationship between patients, their family and the healthcare professional and its impact on patient-centred care.

There is also room for further progress in examining the acceptance and utilisation of patient experience in the development and evaluation of improvement efforts in patient-centred care. Despite the widely acknowledged concept of patient-centred care, the low number of studies found in this review that includes patients’ perspective and experiences of care is professionally and practically concerning.

The conceptual definitions and differentiation between patient experience and satisfaction are still debated in the existing literature [ 19 , 70 , 71 ]. However, in the reviewed studies the authors did not differentiate between these concepts. In some studies in the measurement of patient satisfaction, the focus was on the experience of the process and feeling, rather than the concept of satisfaction where their expectations are met or not. In other studies on patient experience measurement, the focus was on the patients’ expectations. The lack of conceptual differentiation of these concepts could be addressed in future studies as there are implications in their operationalisation and comparability of findings.

Implications for practice

The evidence from the reviewed studies suggests that health services are collecting feedback from patients on their experience either locally or through nationally standardised survey instruments and increasingly reporting them as one of their performance indicators. Not surprisingly, the collection and reporting of patient experience in itself, does not improve care. Considering the evidence from the review, the patient experience collected needs to be discussed and facilitated with healthcare professionals in their respective operational units in order to provide opportunities for them to engage and act on the feedback to improve care.

The finding on the strong focus on interventions targeting communication between healthcare professionals and patients suggests that communication is akin to the ‘delivery’ system for the dimensions of patient-centred care. This could be a consideration for health services as a starting point as it has also been recommended as an area of focus with good cost-benefit to health services [ 72 ].

This review shows that incorporating patient feedback of their experience into research on quality patient-centred care is still an emerging field. The limitations outlined show that the degree of effectiveness attached to the different interventions must be interpreted with caution. However, the findings of this review can inform researchers, healthcare professionals, health systems and policy makers to focus on interventions, practice guidelines and strategies that incorporates patient feedback of their experience in patient-centred care improvement work. Care is truly patient-centred when it is guided by the perspective of the one that matters - the patient.

Availability of data and materials

The data generated or analysed during this study available from corresponding author on reasonable request.

Abbreviations

Consumer Assessment of Healthcare Providers and Systems

National Health Service

Preferred Reporting Items for Systematic Reviews and Meta-Analysis

Mixed Methods Appraisal Tool

Randomized controlled trial

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Sources of support: Eunice Wong is supported by a research higher degree scholarship jointly funded by the Australian Government Research Training Program and Safer Care Victoria. Jane Fisher is supported by the Finkel Professional Fellowship, funded by the Finkel Family Foundation. Beyond funding support, the funders had no direct role in the study design, data collection, analysis, or interpretation, or writing the manuscript.

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Wong, E., Mavondo, F. & Fisher, J. Patient feedback to improve quality of patient-centred care in public hospitals: a systematic review of the evidence. BMC Health Serv Res 20 , 530 (2020). https://doi.org/10.1186/s12913-020-05383-3

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Introduction, section snippets, references (120), cited by (595).

Patient Education and Counseling

Review article patient empowerment, patient participation and patient-centeredness in hospital care: a concept analysis based on a literature review.

• • The interrelationship between the concepts patient empowerment, patient participation and patient-centeredness is clarified.
• • Patient empowerment is a meta-paradigm.
• • Patient participation is a strategy to achieve patient-centered care.
• • A patient-centered approach leads to patient empowerment.
• • The application of the concepts might lead to a better quality of care and a better quality of life .

Conclusions

Practice implications, search strategy concept analysis, definitions, conflicts of interest, acknowledgements, the experiential knowledge of patients: a new resource for biomedical research, soc sci. med., the experience and impact of chronic disease peer support interventions: a qualitative synthesis, patient educ. couns., self-help friendliness: a german approach for strengthening the cooperation between self-help groups and health care professionals, soc. sci. med., the relation between patient-centeredness and patient empowerment: a discussion on concepts, patient empowerment: myths and misconceptions, patient empowerment in theory and practice: polysemy or cacophony, reconsidering patient empowerment in chronic illness: a critique of models of self-efficacy and bodily control, patient empowerment: emancipatory or technological practice, health literacy and patient empowerment in health communication: the importance of separating conjoined twins, toward a theory of patient and consumer activation, empowerment: from philosophy to practice, patient empowerment–who empowers whom, lancet (london, england), back to basics: re-examining the role of patient empowerment in diabetes, self-management approaches for people with chronic conditions: a review, patient participation in the consultation process: a structured review of intervention strategies, engaging patients in health care: an empirical study of the role of engagement on attitudes and action, patient participation: current knowledge and applicability to patient safety, mayo clin. proc., the 9-item shared decision making questionnaire (sdm-q-9) development and psychometric properties in a primary care sample, patient-centredness: a conceptual framework and review of the empirical literature, the evolving concept of patient-centeredness in patient-physician communication research, an evidence base for patient-centered cancer care: a meta-analysis of studies of observed communication between cancer specialists and their patients, strategies for theory construction in nursing, simultaneous concept analysis of spiritual perspective hope, acceptance and self-transcendence, j. nurs. scholarsh., citizen empowerment: a developmental perspective, prev. hum. serv., terms of empowerment/exemplars of prevention: toward a theory for community psychology, am. j. community psychol., global status report on noncommunicable diseases, ottawa charter for health promotion charter, can. j. public health.

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Experiential knowledge: a new concept for the analysis of self-help groups on JSTOR

Soc. serv. rev..

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Effectiveness of strategies for informing, educating, and involving patients

The doctor, his patient and the illness, institute of medicine report: crossing the quality chasm: a new health care system for the 21st century, policy polit. nurs. pract., invest igating organizational quality improvement systems, patient empowerment, organizational culture, professional involvement and the quality of care in european hospitals: the deepening our understanding of quality improvement in europe (duque) proje, bmc health serv. res., why patients should be more empowered: a european perspective on lessons learned in the management of diabetes, j. diabetes sci. technol., effectiveness and efficiency of search methods in systematic reviews of complex evidence: audit of primary sources, theory construction model-building skills: a. practical guide for social scientists, exploring the theoretical basis of nursing using advanced techniques of concept analysis, ans. adv. nurs. sci., methods of concept analysis – a comparative study, lsp j.—lang. spec. purp. prof. commun. knowl. manage. cogn., assessment of patient empowerment – a systematic review of measures, a concept analysis of empowerment in chronic illness from the perspective of the nurse and the client living with chronic obstructive pulmonary disease, j. nurs. healthc. chronic illn., patient empowerment in long-term conditions: development and preliminary testing of a new measure, relationships between patient activation, disease-specific knowledge and health outcomes among people with diabetes; a survey study, patient empowerment: the need to consider it as a measurable patient-reported outcome for chronic conditions, self-management: enabling and empowering patients living with cancer as a chronic illness, ca. cancer j. clin., the perspective of patients on their experience of powerlessness, qual. heal. res., empowerment and self-management of diabetes, clin. diabetes, the psychological processes involved in patient empowerment, orphanet j. rare dis., the diabetes empowerment scale: a measure of psychosocial self-efficacy, diabetes care, the psychometrics of developing the patient empowerment scale, j. psychosoc. oncol., measuring patient empowerment – a systematic review, “same same or different” a review of reviews of person-centered and patient-centered care, the use of big data analytics in healthcare, e-health literacy and associated factors among chronic patients in a low-income country: a cross-sectional survey, whose centre is it anyway defining person-centred care in nursing: an integrative review, patient participation in mental health care – perspectives of healthcare professionals: an integrative review.

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• Reviewing the literature
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• Joanna Smith 1 ,
• Helen Noble 2
• 1 School of Healthcare, University of Leeds , Leeds , UK
• 2 School of Nursing and Midwifery, Queens's University Belfast , Belfast , UK
• Correspondence to Dr Joanna Smith , School of Healthcare, University of Leeds, Leeds LS2 9JT, UK; j.e.smith1{at}leeds.ac.uk

https://doi.org/10.1136/eb-2015-102252

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Implementing evidence into practice requires nurses to identify, critically appraise and synthesise research. This may require a comprehensive literature review: this article aims to outline the approaches and stages required and provides a working example of a published review.

Are there different approaches to undertaking a literature review?

What stages are required to undertake a literature review.

The rationale for the review should be established; consider why the review is important and relevant to patient care/safety or service delivery. For example, Noble et al 's 4 review sought to understand and make recommendations for practice and research in relation to dialysis refusal and withdrawal in patients with end-stage renal disease, an area of care previously poorly described. If appropriate, highlight relevant policies and theoretical perspectives that might guide the review. Once the key issues related to the topic, including the challenges encountered in clinical practice, have been identified formulate a clear question, and/or develop an aim and specific objectives. The type of review undertaken is influenced by the purpose of the review and resources available. However, the stages or methods used to undertake a review are similar across approaches and include:

Formulating clear inclusion and exclusion criteria, for example, patient groups, ages, conditions/treatments, sources of evidence/research designs;

Justifying data bases and years searched, and whether strategies including hand searching of journals, conference proceedings and research not indexed in data bases (grey literature) will be undertaken;

Developing search terms, the PICU (P: patient, problem or population; I: intervention; C: comparison; O: outcome) framework is a useful guide when developing search terms;

Developing search skills (eg, understanding Boolean Operators, in particular the use of AND/OR) and knowledge of how data bases index topics (eg, MeSH headings). Working with a librarian experienced in undertaking health searches is invaluable when developing a search.

Once studies are selected, the quality of the research/evidence requires evaluation. Using a quality appraisal tool, such as the Critical Appraisal Skills Programme (CASP) tools, 5 results in a structured approach to assessing the rigour of studies being reviewed. 3 Approaches to data synthesis for quantitative studies may include a meta-analysis (statistical analysis of data from multiple studies of similar designs that have addressed the same question), or findings can be reported descriptively. 6 Methods applicable for synthesising qualitative studies include meta-ethnography (themes and concepts from different studies are explored and brought together using approaches similar to qualitative data analysis methods), narrative summary, thematic analysis and content analysis. 7 Table 1 outlines the stages undertaken for a published review that summarised research about parents’ experiences of living with a child with a long-term condition. 8

• View inline

An example of rapid evidence assessment review

In summary, the type of literature review depends on the review purpose. For the novice reviewer undertaking a review can be a daunting and complex process; by following the stages outlined and being systematic a robust review is achievable. The importance of literature reviews should not be underestimated—they help summarise and make sense of an increasingly vast body of research promoting best evidence-based practice.

• ↵ Centre for Reviews and Dissemination . Guidance for undertaking reviews in health care . 3rd edn . York : CRD, York University , 2009 .
• ↵ Canadian Best Practices Portal. http://cbpp-pcpe.phac-aspc.gc.ca/interventions/selected-systematic-review-sites / ( accessed 7.8.2015 ).
• Bridges J , et al
• ↵ Critical Appraisal Skills Programme (CASP). http://www.casp-uk.net / ( accessed 7.8.2015 ).
• Dixon-Woods M ,
• Shaw R , et al
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• Jones D , et al
• Cheater F ,

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Competing interests None declared.

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A literature-based study of patient-centered care and communication in nurse-patient interactions: barriers, facilitators, and the way forward

• Abukari Kwame 1 &
• Pammla M. Petrucka 2  

BMC Nursing volume  20 , Article number:  158 ( 2021 ) Cite this article

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Providing healthcare services that respect and meet patients’ and caregivers’ needs are essential in promoting positive care outcomes and perceptions of quality of care, thereby fulfilling a significant aspect of patient-centered care requirement. Effective communication between patients and healthcare providers is crucial for the provision of patient care and recovery. Hence, patient-centered communication is fundamental to ensuring optimal health outcomes, reflecting long-held nursing values that care must be individualized and responsive to patient health concerns, beliefs, and contextual variables. Achieving patient-centered care and communication in nurse-patient clinical interactions is complex as there are always institutional, communication, environmental, and personal/behavioural related barriers. To promote patient-centered care, healthcare professionals must identify these barriers and facitators of both patient-centered care and communication, given their interconnections in clinical interactions. A person-centered care and communication continuum (PC4 Model) is thus proposed to orient healthcare professionals to care practices, discourse contexts, and communication contents and forms that can enhance or impede the acheivement of patient-centered care in clinical practice.

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Providing healthcare services that respect and meet patients’ and their caregivers’ needs are essential in promoting positive care outcomes and perceptions of quality of care, thus constituting patient-centered care. Care is “a feeling of concern for, or an interest in, a person or object which necessitates looking after them/it” [ 1 ]. The Institute of Medicine (IOM) noted that to provide patient-centered care means respecting and responding to individual patient’s care needs, preferences, and values in all clinical decisions [ 2 ]. In nursing care, patient-centered care or person-centered care must acknowledge patients’ experiences, stories, and knowledge and provide care that focuses on and respects patients’ values, preferences, and needs by engaging the patient more in the care process [ 3 ]. Healthcare providers and professionals are thus required to fully engage patients and their families in the care process in meaningful ways. The IOM, in its 2003 report on Health Professions Education , recognized the values of patient-centered care and emphasized that providing patient-centered care is the first core competency that health professionals’ education must focus on [ 4 ]. This emphasis underscored the value of delivering healthcare services according to patients’ needs and preferences.

Research has shown that effective communication between patients and healthcare providers is essential for the provision of patient care and recovery [ 5 , 6 , 7 , 8 ]. Madula et al. [ 6 ], in a study on maternal care in Malawi, noted that patients reported being happy when the nurses and midwives communicated well and treated them with warmth, empathy, and respect. However, other patients said poor communication by nurses and midwives, including verbal abuse, disrespect, or denial from asking questions, affected their perceptions of the services offered [ 6 ]. Similarly, Joolaee et al. [ 9 ] explored patients’ experiences of caring relationships in an Iranian hospital where they found that good communication between nurses and patients was regarded as “more significant than physical care” among patients.

According to Boykins [ 10 ], effective communication is a two-way dialogue between patients and care providers. In that dialogue, both parties speak and are listened to without interrupting; they ask questions for clarity, express their opinions, exchange information, and grasp entirely and understand what the others mean. Also, Henly [ 11 ] argued that effective communication is imperative in clinical interactions. He observed that health and illness affect the quality of life, thereby making health communication critical and that the “intimate and sometimes overwhelming nature of health concerns can make communicating with nurses and other healthcare providers very challenging” [ 11 ]. Furthermore, Henly [ 11 ] added that patient-centered communication is fundamental to ensuring optimal health outcomes, reflecting long-held nursing values that care must be individualized and responsive to patient health concerns. Given the prevalence of face-to-face and device-mediated communications and interactions in healthcare settings, we must explore and clarify who, what, where, when, why, and how interactions with individuals, families, and communities are receiving care and health services [ 11 ].

The value of effective communication in nurse-patient clinical interactions cannot be overemphasized, as “research has shown that communication processes are essential to more accurate patient reporting and disclosure” [ 12 ]. Respectful communication between nurses and patients can reduce uncertainty, enhance greater patient engagement in decision making, improve patient adherence to medication and treatment plans, increase social support, safety, and patient satisfaction in care [ 12 , 13 ]. Thus, effective nurse-patient clinical communication is essential to enhancing patient-centered care and positive care outcomes.

Patient-centered communication, also known as person-centered communication or client-centered communication, is defined as a process that invites and encourages patients and their families to actively participate and negotiate in decision-making about their care needs, as cited in [ 7 ]. Patient-centered communication is crucial in promoting patient-centered care and requires that patients and their caregivers engage in the care process. As McLean [ 14 ] observed, patient-centered care can be enhanced through patient-centered communication by valuing patients’ dignity and rights. Through open communication and collaboration, where information and care plans are shared among care providers, patients, and their families, care provision becomes patient-centered [ 14 ].

Given the interconnected nature of patient-centered care and communication, we must identify the barriers and enablers of patient-centered care and communication and proposed efficient ways to enhance that because patient-centered communication is essential in achieving patient-centered care. Our aim in this paper is to identify the barriers and facilitators of patient-centered care and communication and propose and present a patient-centered care and communication continuum (PC4) Model to explain how patient-centered care can be enhanced in nurse-patient clinical interactions. As Grant and Booth argued, critical reviews are often used to present, analyse, and synthesized research evidence from diverse sources, the outcome of which is a hypothesis or a model as an interpretation of existing data to enhance evidence-based practice [ 15 ]. Thus, this critical literature review study explores the questions: what are the barriers and facilitators of patient-centered care and how can patient-centered care be enhanced through effective clinical communication?

An earlier version of this study was submitted as part of author AK’s doctoral comprehensive exams in February 2021. An interdisciplinary doctoral committee recommended many of the included literature and the questions explored in this study based on the current discourse of patient-centered care advocated for in many healthcare facilities and in recognition of the universal healthcare access objective of the health sustainable development goal. Additional searches for literature were conducted between September and November 2020 using keywords such as barriers and facilitators of nurse-patient interaction, patient-centered care, patient-centered communication , and nurse-patient communication . Databases searched included CINAHL, PubMed, Medline, and Google Scholar. Included studies in this critical review were empirical research on nurse-patient interactions in different care settings published in English and open access. All relevant articles were read, and their main findings relevant to our review questions were identified and organized into themes and subthemes discussed in this paper. Other published studies were read, and together with those that addressed the review question, a model was developed regarding how to enhance patient-centered care through effective communication.

Barriers to Patient-Centered Care and Communication

Nurses constitute a significant workforce of care providers whose practices can severely impact care outcomes (both positive and negative). Nurses spend much time with patients and their caregivers. As a result, positive nurse-patient and caregiver relationships are therapeutic and constitute a core component of care [ 9 , 13 ]. In many instances, nurses serve as translators or patients’ advocates, in addition to performing their primary care duties. Although good nurse-patient relationships positively impact nurse-patient communication and interaction, studies have shown that several factors impede these relationships with significant consequences on care outcomes and quality [ 6 , 16 , 17 ]. Thus, these barriers limit nurses’ and other care providers’ efforts to provide healthcare that meets patients’ and caregivers’ needs. We categorize the barriers to patient-centered care and communication into four kinds: institutional and healthcare system-related, communication-related, environment-related, and personal and behaviour-related barriers. Although these barriers are discussed in separate subheadings, they are interlinked in complex ways during clinical practice.

Institutional and Healthcare System Related Barriers

Many barriers to providing patient-centered care and communication during nurse-patient interactions emanate from healthcare institutional practices or the healthcare system itself. Some of these factors are implicated in healthcare policy or through management styles and strategies.

Shortage of nursing staff, high workload, burnout, and limited-time constituted one complex institutional and healthcare system-level barrier to effective care delivery [ 18 , 19 ]. For instance, Loghmani et al. [ 20 ] found that staffing shortages prevented nurses from having adequate time with patients and their caregivers in an Iranian intensive care unit. Limitations in nursing staff, coupled with a high workload, led to fewer interactions between nurses, patients, and caregivers. Similarly, Anoosheh et al. [ 16 ] found that heavy nursing workload was ranked highest as a limiting factor to therapeutic communication in nurse-patient interactions in Iran.

In a study on communication barriers in two hospitals affiliated with Alborz University of Medical Sciences, Norouzinia et al. [ 21 ] found that shortage of nurses, work overload, and insufficient time to interact with patients were significant barriers to effective nurse-patient interactions. Similar factors are identified as barriers to nurse-patient communication and interactions in other studies [ 13 , 16 , 18 ]. For instance, Amoah et al. [ 16 ] reported that nursing staff shortage and high workload were barriers to patient-centered care and therapeutic communication among Ghanaian nurses and patients. Amoah and colleagues reported a patient’s statement that:

[B]ecause there are few nurses at the ward, sometimes you would want a nurse to attend to you, but he or she might be working on another patient, so in such case, the nurse cannot divide him or herself into two to attend to you both [ 16 ].

Nurses and patients and their caregivers have noted that limited time affects nurse-patient interactions, communication, and care quality. Besides, Yoo et al. [ 22 ] reported that limited visiting hours affected communications between caregivers and nurses in a tertiary hospital in Seoul, Korea. Since the caregivers had limited time to spend with patients, they had little knowledge about the intensive care unit and distrusted the nurses.

Although nursing staff shortage is a significant barrier to patient-centered care and communication that healthcare institutions and managers must know, some healthcare scholars have critique nurses’ complaints of time limitation. For instance, McCabe [ 7 ] argued that the quality of nurse-patient interactions is what matters and not the quantity of time spent with patients and their caregivers. McCabe maintained that “spending long periods with patients does not always result in positive nurse-patient relationships” [ 7 ]. He argued that implementing patient-centered care does not require additional time; hence, nurses’ perceptions of being too busy cannot excuse poor therapeutic communication during clinical interactions. Instead, nurses are encouraged to develop self-awareness, self-reflection, and a commitment to ensuring that patients receive the needed care.

Another institution-related barrier to patient-centered care and communication is the healthcare system’s emphasis on task-centered care. Care providers are more focused on completing care procedures than satisfying patients’ and caregivers’ needs and preferences. This barrier to patient-centered care and communication is acknowledged in several studies [ 7 , 14 , 20 , 22 , 23 ]. For example, McLean [ 14 ] studied dementia care in nursing homes in the United States. She found that patient-centered care and communication in one nursing home (Snow I) were severely affected when nurses, physicians, and care managers focused on completing tasks or observing care and institutional routines to the detriment of satisfying patients’ care needs. However, in the other care home (Snow II), patient-centered care was enhanced as nurses, physicians, and the care home managers focused on addressing patients’ needs and values rather than completing care routines and tasks.

Similarly, Yoo and colleagues [ 22 ] observed that nurse-patient communication was affected when the ICU nurses placed urgency on completing tasks linked directly to patients’ health (e.g., stabilizing vital signs) than communicating to addressed patients’ specific needs. This evidence shows that when nurses are more task-focused, patients and caregivers are treated as bodies and objects, on which medical and care practices must be performed to restore health. Research has shown that when nurses focus on task-oriented care, it becomes hard to provide holistic care to patients or teach and communicate with patients even when nurses are less busy [ 20 ].

Nursing managers and their management styles can affect patient-centered care and communication. Studies have revealed that the management styles that nursing managers implement can either facilitate or impede patient-centered care [ 14 , 22 ]. When nurse managers orient their nursing staff towards task-centered care practices, it affects nurse-patient interaction and communication. Moreover, when nurse managers fail to address their staff’s mental health needs and personal challenges, it influences how nurses attend to patients’ care needs. For example, nurses have indicated that nurse-patient communication is affected when nurse managers are unsupportive or unresponsive to their needs [ 20 ].

In a study exploring nursing and midwifery managers’ perspectives on obstacles to compassion giving and therapeutic care across 17 countries, Papadopoulos et al. [ 24 ] discovered that nurses and midwifery managers’ characteristics and experiences could facilitate or impede compassion and therapeutic interactions in nursing care. Negative personal attitudes, including selfishness, arrogance, self-centeredness, rudeness, lack of leadership skills, the desire for power, and feelings of superiority among nurses and midwifery managers, were obstacles to compassion building. The study further showed that managers who emphasize rules, tasks, and results do not prioritize relationship-building and see their staff as workers rather than team members [ 24 ]. Therefore, nurse managers and care administrators must monitor nurse-patient interaction and communication to address nurses’ concerns and support them, especially in resource-constrained and high patient turnover contexts [ 25 , 26 ].

Communication-Related Barriers

Effective communication is essential to providing patient-centered care. Studies have shown that poor communication between care providers and patients and their caregivers affects care outcomes and perceptions of care quality [ 7 , 16 , 27 , 28 ]. A consistent communication-related barrier in nurse-patient interaction is miscommunication, which often leads to misunderstandings between nurses, patients, and their families [ 20 ]. Other communication-related barriers include language differences between patients and healthcare providers [ 6 , 16 , 27 ], poor communication skills, and patients’ inability to communicate due to their health state, especially in ICU, dementia, or end-of-life care contexts [ 13 , 22 ]. For instance, in their maternity care study, Madula et al. [ 6 ] noted that language barriers significantly affected effective communication between nurses/midwives and expectant mothers. A patient in their study indicated that although many nurses were polite and communicated well, some nurses had challenges communicating with patients in the Chitumbuka language, which affected those nurses’ ability to interact effectively with patients [ 6 ].

Furthermore, Norouzinia et al. [ 21 ] asserted that effective communication could not be established when nurses and patients have a language difference. Moreover, the meanings of certain non-verbal communication acts (e.g., head nodding, eye gaze, touch) can invoke different interpretations across different cultures, which could impede the interactions between patients and nurses. Even in healthcare contexts where nurses and patients speak the same language, “differences in vocabulary, rate of speaking, age, background, familiarity with medical technology, education, physical capability, and experience can create a huge cultural and communication chasm” between nurses and patients [ 12 ]. In ICU and other similar care settings, nurses find it difficult to effectively communicate with patients because the mechanical ventilators made it hard for patients to talk [ 22 ].

To overcome the communication-related barriers, healthcare institutions must make it a responsibility to engage translators and interpreters to facilitate nurse-patient interactions where a language barrier exists. Moreover, nurses working in ICU and other similar settings should learn and employ alternative forms of communication to interact with patients.

Environment-Related Barriers

The environment of the care setting can impact nurse-patient communication and the resulting care. Thus, “good health care experiences start with a welcoming environment” [ 29 ]. Mastors believed that even though good medicine and the hands working to provide care and healing to the sick and wounded are essential, we must not “forget the small things: a warm smile, an ice chip, a warm blanket, a cool washcloth. A pillow flipped to the other side and a boost in bed” [ 29 ]. The environment-related barriers are obstacles within the care setting that inhibit nurse-patient interaction and communication and may include a noisy surrounding, unkept wards, and beds, difficulties in locating places, and navigating care services. Noisy surroundings, lack of privacy, improper ventilation, heating, cooling, and lighting in specific healthcare units can affect nurse-patient communication. These can prevent patients from genuinely expressing their healthcare needs to nurses, which can subsequently affect patient disclosure or make nursing diagnoses less accurate [ 13 , 18 , 21 ]. For instance, Amoah et al. [ 16 ] revealed that an unconducive care environment, including noisy surroundings and poor ward conditions, affected patients’ psychological states, impeding nurse-patient relationships and communication. Moreover, when care services are not well-coordinated, new patients and their caregivers find it hard to navigate the care system (e.g., locating offices for medical tests and consultations), which can constrain patient-centered care and communication.

Reducing the environment-related barriers will require making the care setting tidy/clean, less noisy, and coordinating care services in ways that make it easy for patients and caregivers to access. Coordinating and integrating care services, making care services accessible, and promoting physical comfort are crucial in promoting patient-centered care, according to Picker’s Eight Principles of Patient-Centered Care [ 30 ].

Personal and Behaviour Related Barriers

The kind of nurse-patient relationships established between nurses and patients and their caregivers will affect how they communicate. Since nurses and patients may have different demographic characteristics, cultural and linguistic backgrounds, beliefs, and worldviews about health and illnesses, nurses’, patients’, and caregivers’ attitudes can affect nurse-patient communication and care outcomes. For instance, differences in nurses’ and patients’ cultural backgrounds and belief systems have been identified as barriers to therapeutic communication and care [ 12 , 13 , 21 ]. Research shows that patients’ beliefs and cultural backgrounds affected their communication with nurses in Ghana [ 16 ]. These scholars found that some patients refused a blood transfusion, and Muslim patients refused female nurses to attend to them because of their religious beliefs [ 16 ]. Further, when nurses, patients, or their caregivers have misconceptions about one another due to past experiences, dissatisfaction about the care provided, or patients’ relatives and caregivers unduly interfere in the care process, nurse-patient communication and patient-centered care were affected [ 16 , 21 ].

Similarly, nurse-patient communication was affected when patients or caregivers failed to observe nurses’ recommendations or abuse nurses due to misunderstanding [ 20 ], while patients’ bad attitudes or disrespectful behaviours towards nurses can inhibit nurses’ ability to provide person-centered care [ 31 ]. The above-reviewed studies provided evidence on how patients’ and caregivers’ behaviours can affect nurses’ ability to communicate and deliver patient-centered care.

On the other hand, nurses’ behaviours can also profoundly affect communication and care outcomes in the nurse-patient dyad. When nurses disrespect, verbally abuse (e.g., shouting at or scolding), and discriminate against patients based on their social status, it affects nurse-patient communication, care outcomes, and patient disclosure [ 6 , 32 ]. For instance, Al-Kalaldeh et al. [ 18 ] believe that nurse-patient communication is challenged when nurses become reluctant to hear patients’ feelings and expressions of anxiety. When nurses ignore patients’ rights to share ideas and participate in their care planning, such denials may induce stress, discomfort, lack of trust in nurses, thereby leading to less satisfaction of care [ 18 ].

Furthermore, when nurses fail to listen to patients’ and caregivers’ concerns, coerce patients to obey their rules and instructions [ 16 , 17 , 20 ], or fail to provide patients with the needed information, nurse-patient communication and patient-centered care practices suffer. To illustrate, in Ddumba-Nyanzia et al.‘s study on communication between HIV care providers and patients, a patient remarked that: “I realized no matter how much I talked to the counselor, she was not listening. She was only hearing her point of view and nothing else, [and] I was very upset” [ 17 ]. This quote indicates how care provider attitudes can constrain care outcomes. Due to high workload, limited time, poor remunerations, and shortage of personnel, some nurses can develop feelings of despair, emotional detachment, and apathy towards their job, which can lead to low self-esteem or poor self-image, with negative consequences on nurse-patient interactions [ 13 , 18 ].

Given the significance of effective communication on care, overcoming the above personal and behaviour related barriers to patient-centered care and communication is crucial. Nurses, patients, and caregivers need to reflect on the consequences of their behaviours on the care process. Thus, overcoming these barriers begins with embracing the facilitators of patient-centered care and communication, which we turn to in the next section.

Facilitators of patient-centered care and communication

Patient-centered care and communication can be facilitated in several ways, including building solid nurse-patient relationships.

First, an essential facilitator of patient-centered care and communication is overcoming practical communication barriers in the nurse-patient dyad. Given the importance of communication in healthcare delivery, nurses, patients, caregivers, nursing managers, and healthcare administrators need to ensure that effective therapeutic communication is realized in the care process and becomes part of the care itself. Studies have shown that active listening among care providers is essential to addressing many barriers to patient-centered care and communication [ 7 , 13 ]. Although handling medical tasks promptly in the care process is crucial, the power of active listening is critical, meaningful, and therapeutic [ 22 ]. By listening to patients’ concerns, nurses can identify patients’ care needs and preferences and address their fears and frustrations.

Another facilitator of patient-centered care is by understanding patients and their unique needs [ 25 ], showing empathy and attending attitudes [ 7 , 13 ], expressing warmth and respect [ 22 ], and treating patients and caregivers with dignity and compassion as humans. For instance, McCabe [ 7 ] noted that attending, which obligates nurses to demonstrate that they are accessible and ready to listen to patients, is a patient-centered care process; a fundamental requirement for nurses to show genuineness and empathy, despite the high workload. Showing empathy, active listening, respect, and treating patients with dignity are core to nursing and care, and recognized in the Code of Ethics for Nurses [ 33 ], and further emphasized in the ongoing revision of the Code of Ethics for nurses [ 34 ].

Besides, engaging patients and caregivers in the care process through sharing information, inviting their opinion, and collaborating with them constitutes another facilitator of patient-centered care and communication. When patients and caregivers are engaged in the care process, misunderstandings and misconceptions are minimized. When information is shared, patients and caregivers learn more about their health conditions and the care needed. As McLean [ 14 ] argued, ensuring open communication between care providers and patients and their families is essential to enhancing patient-centered care. Conflicts ensue when patients or their families are denied information or involvement in the care process. As a result, the Harvard Medical School [ 30 ] identified patient engagement, information sharing, and nurse-patient collaboration during care as essential patient-centered care principles.

Finally, health policy must be oriented towards healthcare practices and management to facilitate patient-centered care and communication. These policies, at a minimum, can involve changes in management styles within healthcare institutions, where nurse managers and healthcare administrators reflect on nursing and care practices to ensure that the Code of Ethics of Nurses and patients’ rights are fully implemented. Resource constraints, staff shortages, and ethical dilemmas mainly affect care practices and decision-making. Nonetheless, if patients are placed at the center of care and treated with dignity and respect, most of the challenges and barriers of patient-centered care will diminish. Empowering practicing nurses, equipping them with interpersonal communication skills through regular in-service training, supporting them to overcome their emotional challenges, and setting boundaries during nurse-patient interactions will enhance patient-centered care practices.

In line with the above discussion, Camara et al. [ 25 ] identify three core dimensions that nurses, patients, and caregivers must observe to enhance patient-centered care: treating the patient as a person and seeing the care provider as a person and a confidant. Regarding the first dimension, care providers must welcome patients, listen to them, share information with them, seek their consent, and show them respect when providing care. The second dimension requires that the healthcare provider be seen and respected as a person, and negative perceptions about care providers must be demystified. According to Camara et al. [ 25 ], care providers must not overemphasize their identities as experts but rather establish good relationships with patients to understand patients’ personal needs and problems. Lastly, patients and caregivers must regard care providers as confidants who build and maintain patients’ trust and encourage patients’ participation in care conversations. With this dimension, patients and caregivers must know that nurses and other care providers have the patient at heart and work to meet their care needs and recovery process.

Camara et al.‘s [ 25 ] three dimensions are essential and position patients, their caregivers, and nurses as partners who must engage in dialogic communication to promote patient-centered care. As a result, effective communication, education, and increased health literacy among patients and caregivers will be crucial in that direction.

Enhancing Patient-Centered Care and Communication: A Proposed Model

Nursing care practices that promote patient-centered communication will directly enhance patient-centered care, as patients and their caregivers will actively engage in the care process. To enhance patient-centered communication, we propose person-centered care and communication continuum (PC4) as a guiding model to understand patient-centered communication, its pathways, and what communication and care practices healthcare professionals must implement to achieve person-centered care. In this PC4 Model, we emphasize the person instead of the patient because they are a person before becoming a patient. Moreover, the PC4 Model is supposed to apply to all persons associated with patient care; thus, respect for the dignity of their personhood is crucial.

Although much is written about patient-centered communication in the healthcare literature, there is a gap regarding its trajectory and what communication content enhances patient-centered communication. Also, little is known about how different clinical discourse spaces influence communication and its content during nurse-patient clinical interactions. Using evidence from Johnsson et al. [ 3 ], Murira et al. [ 23 ], and Liu et al. [ 35 ], among other studies, we outline the components of the PC4 Model and how different discourse spaces in the clinical setting and the content of communication impact patient-centered care and communication.

The proposed PC4 Model in this paper has three unbounded components based on the purpose of and how communication is performed among care providers, patients, and their caregivers. Figure  1 illustrates the PC4 Model, its features, and trajectory.

A Person-Centered Care and Communication Continuum (PC4 Model)

Task-Centered Communication

At the lowest end of the PC4 Model is task-centered communication. Here, the care provider’s role is to complete medical tasks as fast as possible with little or no communication with the patient and their caregivers. Patients and caregivers are treated as bodies or objects whose disease symptoms need to be studied, identified, recorded, treated, or cured. As Johnsson et al. [ 3 ] observed, communication content at this stage is mainly biomedically oriented, where nurses and other healthcare professionals focus on the precise medical information (e.g., history taking, medical examination, test results, medication, etc.) about the patient. With a task-centered orientation, nurses make journal entries about their patients’ disease state and ensure that treatment plans, diagnostic tests, and medical prescriptions are completed. Communication at this stage is often impersonal or rigid (see [ 23 ] for details). Care providers may address patients and their caregivers by using informal attributes (e.g., bed 12, the woman in the red shirt, card 8, etc.), thereby ignoring patients’ and caregivers’ personal and unique identities. Patients’ and caregivers’ nonverbal communication signs are mostly overlooked.

Motivations for task-centered communication can be attributed to time limitation, high workload, and staff shortage, thereby pushing nurses and other care providers to reach as many patients as possible. Moreover, the healthcare system’s orientation towards and preference for biomedically-focused care seems to favour task-centered communication [ 7 , 14 ].

Depending on the clinical discourse space under which patient-provider interactions occur, different forms of communication are employed. Clinical discourse spaces can be public (e.g., in the ward, patient bedside), private (e.g., consulting rooms, medical test labs, nurse staff station, etc.), or semi-private (e.g., along the corridor) [ 35 ]. In these clinical discourse spaces, nurse-patient communication can be uninformed (patients or caregivers are not informed about patients’ care conditions or why specific data and routines are performed). It can be non-private (others can hear what the nurse and patient are talking about) or authoritative (care providers demonstrate power and control and position themselves as experts) [ 23 ]. Finally, in task-centered communication, healthcare providers often use medical jargon or terminologies [ 3 ] since the goal of communication is not to engage the patient in the process. Usually, patients or their caregivers are not allowed to ask questions, or their questions get ignored or receive superficial, incomprehensible responses.

Process-Centered Communication

Process-centered communication is an intermediate stage on the continuum, which could slip back into the task-centered or leap forward into person-centered communication. Through process-centered communication, care providers make an effort to know patients and their caregivers as they perform care routines. Care providers ask patients or their caregivers questions to understand the care conditions but may not encourage patients or caregivers to express their thoughts about their care needs. Patients and caregivers are recognized as persons with uniques care needs but may not have the agency to influence the care process. Care providers may chit-chat with patients or their caregivers to pass the time as they record patients’ medical records or provide care. Unlike task-centered communication, there is informative and less authoritative communication between nurses and patients and their caregivers. The goal of process-centered communication could be a mixture of instrumental and relational, with less display of power and control by nurses.

Person-Centered Communication

This is the highest point of the PC4 Model, where patient-centered care is actualized. At this stage of the communication continuum, patients and caregivers are treated as unique persons with specific care needs and are seen as collaborators in the care process. As McLean [ 14 ] observed, caregiving becomes a transactional relationship between the care provider and receiver at the person-centered stage of the continuum. The care itself becomes intersubjective, a mutual relational practice, and an ongoing negotiation for care providers and receivers [ 14 ].

The content of communication at this stage of the continuum is both “personal” and “explanatory” [ 3 ]. Nurses and other healthcare providers create meaningful relationships with patients and their caregivers, understand patients’ concerns, needs, and problems, use open-ended questions to encourage patients or caregivers to express their thoughts and feelings about the care situation. Nurses and other healthcare professionals explain care routines, patients’ health conditions, and management plans in lay language to patients and caregivers through person-centered communication. Accomplishing this level includes employing alternative forms of communication to meet the needs of intensive care unit patients, deaf patients, and ventilated and intubated patients. For instance, it has been shown that “deaf people […] frequently do not have access to clear and efficient communication in the healthcare system, which deprives them of critical health information and qualified health care” [ 36 ]. Empathetic communication practices, including active listening, showing genuine interest in patients’ care, and respect and warmth, become a significant part of nursing care [ 3 , 7 , 14 , 22 ].

Different communication strategies are employed based on the care situation and context. Chit-chatting, as a form of personal communication [ 3 ], use of humor as a communication strategy [ 7 , 8 ], and even maintaining silence [ 28 ] are essential in enhancing person-centered care and communication. Both care providers and patients or their caregivers use relationship-building and -protecting humor (see [ 28 ] for details) to address difficult situations in the care process.

Implications of the PC4 Model for Nursing Practice

Given the values of effective communication in nurse-patient interactions and care outcomes, nurses and other healthcare providers must ensure that they develop therapeutic relationships with patients, their families, and caregivers to promote person-centered care and communication. Achieving that begins with knowing and reflecting on the barriers of therapeutic communication and ways to minimize them. The PC4 Model draws nurses and all healthcare providers’ attention to patient-centered care pathways and how effective communication is necessary. Healthcare professionals, including nurses, must be aware of how their communication orientation–––either oriented toward completing tasks, following care processes or toward addressing patients’ and their caregivers’ needs––can impact patient-centered care. Healthcare providers must observe the care context, patients’ unique situations, their non-verbal language and action, and whether they belong to historically marginalized groups or cultures.

Mastors [ 29 ] has offered healthcare providers some guidance to reflect on as they communicate and interact with patients and caregivers. Thus, (a) instead of asking patients, “What’s the matter?“ care providers must consider asking them, “What’s important to you?“ With this question, the patient is given a voice and empowered to contribute to their own care needs. Care providers should (b) check with patients in the waiting room to update patients whose waiting time has been longer than usual, based on the care context. They should also (c) try to remember their conversations with patients to build on them during subsequent interactions. This continuity can be enhanced by nurse managers reexamining how they deploy care providers to patients. The same nurse can be assigned to the same patients for the duration of the patient’s stay to help patients feel valued and visible [ 29 ].

Knowledge of cultural competence, sensitivity, humility, and interpersonal communication skills will help achieve and implement the PC4 Model. As Cuellar [ 37 ] argues, “[h]umility is about understanding and caring for all people [and] being empathetic.“ Cultural competence is a “dynamic process of acquiring the ability to provide effective, safe, and quality care to the patients through considering their different cultural aspects” [ 38 ]. The concept of cultural competence entails “cultural openness, awareness, desire, knowledge and sensitivity” during care [ 39 ]. It demands that care providers respect and tailor care to align with patients’ and caregivers’ values, needs, practices, and expectations, based on care and moral ethics and understanding [ 39 ]. Active listening and showing compassion as therapeutic relationship-building skills are essential, and continuous education and mentorship will be crucial to developing these skills among healthcare providers.

We invite qualitative and quantitative studies, especially on language use and communication strategies, to explore and evaluate the PC4 Model. Providing in-depth and experiential data on ways to increase its effectiveness as a tool to guide healthcare providers is highly desired. More knowledge can support healthcare providers in offering evidence-based patient-centered care in different healthcare settings and units.

Conclusions

Effective communication is an essential factor in nurse-patient interactions and a core component of nursing care. When communication in the nurse-patient dyad is patient-centered, it becomes therapeutic. It allows for trust and mutual respect in the care process, thereby promoting care practices that address patients’ and caregivers’ needs, concerns, and preferences. We have identified the barriers and facilitators of patient-centered care and communication and proposed a person-centered care and communication continuum (PC4 Model) to demonstrate how patient-centered communication intersects with patient-centered care.

Availability of data and materials

Not applicable.

Abbreviations

Intensive Care Unit

Institution of Medicine

Person-Centered Care and Communication Continuum

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Acknowledgments

We express our gratitude to the first author’s doctoral committee members for their valuable comments, suggestions, and critique of an earlier version of this paper. We are also grateful to the anonymous reviewers for the insightful comments and suggestions that have helped us improve the study’s quality.

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Abukari Kwame is a Ph.D. candidate in Interdisciplinary Studies in the College of Graduate and Postdoctoral Studies, University of Saskatchewan, interested in patients' rights in nurse-patient clinical communications and interactions in the hospital setting. He holds two Master of Philosophy degrees in Indigenous Studies and English Linguistics. Abukari's research interests include language use in social interaction, health communication, First/Second language acquisition, African traditional medical knowledge, and Indigenous and qualitative research methodologies.

Pammla M. Petrucka is a professor in Nursing and has international research experience with many of her graduate students from Africa, Asia, and the Caribbean. Pammla has published extensively in the field of nursing. Her research interests are vast, including child and maternal health, Indigenous peoples' health, global health, and vulnerable populations, with extensive experiences in qualitative research and indigenous research methodologies. Pammla is co-editor of the BMC Nursing journal and a reviewer for many other academic journals.

The authors have not received any funding for the conduct, preparation, and publication of this paper.

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Both authors conceived the topic. PMP recommended the literature, AK searched and added more sources, and drafted the paper. PMP reviewed the paper for intellectual content. Both AK and PMP read and approved the final version.

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Kwame, A., Petrucka, P.M. A literature-based study of patient-centered care and communication in nurse-patient interactions: barriers, facilitators, and the way forward. BMC Nurs 20 , 158 (2021). https://doi.org/10.1186/s12912-021-00684-2

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Critically ill patients with newly diagnosed anti-neutrophil cytoplasmic antibody-associated vasculitis: case series and literature review.

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Rukavina, K.; Zlopasa, O.; Vukovic Brinar, I.; Dzubur, F.; Anic, B.; Vujaklija Brajkovic, A. Critically Ill Patients with Newly Diagnosed Anti-Neutrophil Cytoplasmic Antibody-Associated Vasculitis: Case Series and Literature Review. J. Clin. Med. 2024 , 13 , 5688. https://doi.org/10.3390/jcm13195688

Rukavina K, Zlopasa O, Vukovic Brinar I, Dzubur F, Anic B, Vujaklija Brajkovic A. Critically Ill Patients with Newly Diagnosed Anti-Neutrophil Cytoplasmic Antibody-Associated Vasculitis: Case Series and Literature Review. Journal of Clinical Medicine . 2024; 13(19):5688. https://doi.org/10.3390/jcm13195688

Rukavina, Kresimir, Ozrenka Zlopasa, Ivana Vukovic Brinar, Feda Dzubur, Branimir Anic, and Ana Vujaklija Brajkovic. 2024. "Critically Ill Patients with Newly Diagnosed Anti-Neutrophil Cytoplasmic Antibody-Associated Vasculitis: Case Series and Literature Review" Journal of Clinical Medicine 13, no. 19: 5688. https://doi.org/10.3390/jcm13195688

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Mapping Distributed Ledger Technology Characteristics to Use Cases in Healthcare: A Structured Literature Review

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Bibliometrics & citations, view options, 1 introduction, 2 background and related work, 2.2 related work.

3.1 Data Collection

TITLE-ABSTR-KEY (distributed ledger technology OR DLT OR blockchain) AND TITLE-ABSTR-KEY (health* OR medical) AND TITLE-ABSTR-KEY (application OR scenario OR use case)

3.2 Data Analysis

4.1 Patient-Centric Health Data Management

4.1.1 use case description..

4.1.2 Access Management.

4.1.3 secure record-keeping., 4.1.4 data sharing incentivization., 4.2 management of electronic healthcare records (ehrs), 4.2.1 use case description..

4.2.2 Access Management.

4.2.3 secure record-keeping., 4.3.1 use case description..

4.3.2 Access Management.

4.3.3 secure record-keeping., 4.3.4 process automation., 4.4 biomedical research, 4.4.1 use case description..

4.4.2 Access Management.

4.4.3 secure record-keeping., 4.4.4 data sharing incentivization., 4.4.5 process automation., 4.5 supply chain management (scm) for pharmaceutical drugs or medical devices, 4.5.1 use case description..

4.5.2 Secure Record-Keeping.

4.5.3 process automation., 4.6 contact tracing and warning for pandemics, 4.6.1 use case description..

4.6.2 Secure Record-Keeping.

4.6.3 process automation., 5 discussion, 5.1 principal findings, 5.2 implications.

5.3 Limitations and Future Research

6 conclusion, a.1. dlt characteristics.

A.2. Rationale for Characteristics

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Applied computing

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Human rights education in patient care: A literature review and critical discussion

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• 1 1724University of Birmingham, UK.
• 2 58716Sue Ryder, UK.
• PMID: 32552480
• DOI: 10.1177/0969733020921512

The identification of human rights issues has become more prominent in statements from national and international nursing organisations such as the American Nurses Association and the United Kingdom's Royal College of Nursing with the International Council of Nursing asserting that human rights are fundamental to and inherent in nursing and that nurses have an obligation to promote people's health rights at all times in all places.However, concern has been expressed about this development. Human rights may be seen as the imposition of legal considerations for nurses and other healthcare workers to bear in mind, as yet more responsibilities with the consequent fear of litigation. Although a more hopeful scenario is that consideration of human rights is something that is supportive of good practice.If this more hopeful scenario is to be realised, the role of education will be crucial. As with human rights generally, human rights education is a global phenomenon, a practice-orientated expression of the Universal Declaration of Human Rights, and the goal of human rights education is to build a culture of respect and action for human rights for all.However, the nature of human rights has long been contested. A 'mapping exercise' of the academic literature on human rights identified 'four schools' or 'ideal types' that have shaped thinking about human rights. This sets out the conceptual context in which human rights problems are defined and solutions are proposed, which is particularly important for human rights education. However, it also complicates the picture. The different approaches taken by the four 'types' would likely lead to different outcomes in terms of human rights education.It is timely to discuss the nature of human rights education and examine its potential for impact on patient care. This will involve identifying the challenges and potential benefits of this approach and analysing the implications for professional practice.

Keywords: Activist; decision making; empowerment; human rights; patient care.

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Predictors of acute kidney injury in dengue patients: a systematic review and meta-analysis

• Abdelaziz A. Awad 1   na1 ,
• Mahalaqua Nazli Khatib 2   na1 ,
• Abhay M Gaidhane 3 ,
• Suhas Ballal 4 ,
• Pooja Bansal 5 ,
• Manish Srivastava 6 ,
• Isha Arora 7 ,
• M Ravi Kumar 8 ,
• Aashna Sinha 9 ,
• Pramod Rawat 10 , 11 ,
• Sanjit Sah 12 , 13 ,
• Ganesh Bushi 14 ,
• Sorabh Lakhanpal 15 &
• Muhammed Shabil 16 , 17  

Virology Journal volume  21 , Article number:  223 ( 2024 ) Cite this article

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Dengue infection poses a significant global health challenge, particularly in tropical and subtropical regions. Among its severe complications, Acute kidney injury (AKI) stands out due to its association with increased morbidity, mortality, and healthcare burdens. This Meta-analysis aim to identify and evaluate the predictors of AKI among dengue patients, facilitating early detection and management strategies to mitigate AKI’s impact.

We searched PubMed, EMBASE, and Web of Science databases, covering literature up to February 2024. We included human observational studies reporting on AKI predictors in confirmed dengue cases. Nested-Knowledge software was used for screening and data extraction. The Newcastle-Ottawa Scale was used for quality assessment. R software (V 4.3) was utilized to compute pooled odds ratios (ORs) and 95% confidence intervals (CIs) for each predictor.

Our search yielded nine studies involving diverse geographic locations and patient demographics. A total of 9,198 patients were included in the studies, with 542 diagnosed with AKI. in which key predictors of AKI identified include severe forms of dengue (OR: 2.22, 95% CI: 1.02–3.42), male gender (OR: 3.13, 95% CI: 1.82–4.44), comorbidities such as diabetes mellitus (OR: 3.298, 95% CI: 0.274–6.322), and chronic kidney disease (OR: 2.2, 95% CI: 0.42–11.24), as well as co-infections and clinical manifestations like rhabdomyolysis and major bleeding.

Our study identifies several predictors of AKI in dengue patients. These findings indicate the importance of early identification and intervention for high-risk individuals. Future research should focus on standardizing AKI diagnostic criteria within the dengue context and exploring the mechanisms underlying these associations to improve patient care and outcomes.

Introduction

Dengue represents a significant global public health challenge, especially in tropical and subtropical regions, affecting millions yearly [ 1 , 2 , 3 ]. It manifests in a spectrum ranging from mild, flu-like symptoms to severe conditions, including dengue hemorrhagic fever, severe dengue, and dengue shock syndrome [ 1 ]. A particularly concerning complication of dengue is acute kidney injury (AKI), associated with increased morbidity, extended hospital stays, and elevated mortality rates [ 4 , 5 , 6 ]. The mechanisms predisposing individuals to AKI during an infection with dengue virus have yet to be fully understood, complicating early detection and effective management.

The reported prevalence of AKI among those with dengue varies widely [ 5 ]. This variation is influenced by several factors, including geographic differences, the specific serotypes of the dengue virus present, demographic factors of the populations studied, and the criteria used to define AKI clinically [ 7 ]. For example, regions with limited healthcare resources might underreport AKI cases due to a scarcity of diagnostic capabilities or a lack of healthcare provider awareness [ 8 , 9 ]. Moreover, certain dengue virus serotypes have been linked to more severe disease manifestations and, consequently, an increased risk of AKI [ 10 , 11 ]. Identifying AKI predictors in the context of dengue is crucial for developing strategies that can effectively detect, categorize risks, and intervene early to minimize the incidence and impact of AKI. Demographic factors such as age, gender, and existing comorbidities significantly affect the risk of developing AKI in dengue patients. Older individuals and those with underlying conditions, like diabetes, hypertension, or chronic kidney disease, are particularly at high risk to AKI during dengue infection [ 12 ]. Additionally, studies suggest that males might have a higher risk of severe dengue and subsequent AKI, indicating a complex interaction of genetic, hormonal, and environmental factors [ 11 , 13 , 14 ]. The use of varied criteria across studies to define AKI, including the Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease (RIFLE) criteria, the Acute Kidney Injury Network (AKIN) criteria, or the Kidney Disease: Improving Global Outcomes (KDIGO) criteria, complicates the understanding of the true prevalence of AKI in dengue infections [ 15 ]. These inconsistencies highlight the need for standardized diagnostic and reporting protocols for AKI in the context of dengue, facilitating more accurate study comparisons and analyses.

Understanding the factors influencing AKI development in dengue patients is critical, as it aids in the early identification of AKI and facilitates timely intervention. This systematic review seeks to elucidate the predictors of AKI in individuals infected with dengue, providing a foundation for improved patient care and outcomes.

The systematic review and meta-analysis were conducted in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [ 16 ], as detailed in Table S1 . The review protocol was officially registered in the Prospero database under the registration number: CRD42024517289. Nested knowledge web software (Nested-Knowledge, MN, USA) was used in this study for screening of articles and data extraction.

Literature search strategy

A comprehensive search was performed across three electronic databases: PubMed, EMBASE, and Web of Science. The search covered records from their inceptions until December 20, 2023, with an update on February 15, 2024. The search strategy employed keywords and MeSH terms. A detailed description of the search strategy is available in Table S2. Searches were conducted without any restrictions based on language, publication type, or publication year.

Inclusion and exclusion criteria

Inclusion criteria were set to human observational studies, such as cross-sectional, case-control, or cohort studies, that reported on AKI and its predictors among dengue patients. No restrictions were imposed on the demographics of the eligible population. Only confirmed dengue cases were considered. Exclusion criteria were case reports, case series, review articles, letters, in vitro and animal studies, conference abstracts, and studies that did not distinguish between severe and non-severe dengue outcomes. Only studies published in English with clearly stated criteria for AKI diagnosis were included .

Study selection

The articles retrieved from databases were imported into Nested Knowledge web software for initial screening, where duplicates were removed. Titles and abstracts were preliminarily reviewed, followed by full-text screening to determine final inclusion. Two independent reviewers carried out this process, with any disagreements resolved through discussion or consulting a third reviewer.

Data extraction and quality evaluation

Data extraction was performed by two reviewers (SB and MS), with any differences resolved by mutual consensus. Extracted data included the first author’s name, country of study, study design, sample size, study population demographics, median or mean age, percentage of male participants, predictors of AKI, and their associated estimates. We used the “tagging” function of Nested Knowledge software to aid data extraction. The Newcastle-Ottawa Scale (NOS) was utilized to assess the quality of the included studies. Reviewers (SB and MS) conducted this quality assessment independently, with any discrepancies resolved through consensus or the involvement of an additional author (MNK).

Statistical analysis

In our analysis, we employed a random-effects model to compute the pooled odds ratios (ORs) and 95% confidence intervals (CIs) for each identified predictor of AKI, specifically employing the Restricted Maximum Likelihood (REML) method for estimating between-study variance [ 17 ]. This model was selected to better accommodate the expected variability across studies due to population, design, and methodology differences, thus providing a more accurate estimation of the true effect size. To evaluate the heterogeneity among the included studies, we utilized tau-square and I 2 statistics, categorizing heterogeneity levels as low (< 25%), low to moderate (25% to < 50%), moderate to high (50% to < 75%), or high (≥ 75%) [ 18 , 19 ]. These categories help to understand the variance among study outcomes and the generalizability of our findings. All statistical analyses were performed using R software, version 4.3 [ 20 ].

Literature search and study characteristics

The search for literature in the systematic review commenced with identifying 2,690 records through various databases: 556 from PubMed, 1,413 from Embase, and 721 from Web of Science. Before screening, duplicates were meticulously removed, totalling 829 records. The screening process was then conducted on 1,861 records. No reports were excluded as not retrievable, resulting in 275 reports sought for full-text retrieval. Upon a thorough assessment of these full texts for eligibility, 266 articles were excluded for the following reasons: 201 due to the outcome of interest not being specified, 11 for being non-human studies, and 54 for not reporting the predictors of interest. Ultimately, nine studies were included in the review (Fig.  1 ).

PRISMA flowchart depicting article selection and screening process

The characteristics of the included studies are presented in Table  1 . Two of the nine studies were from India [ 11 , 21 ], two from Thailand [ 14 , 22 ] while other studies conducted in Indonesia [ 23 ], Vietnam [ 13 ], Pakistan [ 24 ], Malaysia [ 4 ], and China [ 7 ]. A total of 9,198 patients were included in the studies, with 542 diagnosed with AKI. Most of these studies employed a retrospective design, indicative of the common approach to analyzing clinical outcomes in existing patient data, except for a single cross-sectional study from Vietnam, which provided insights into the prevalence of AKI among hospitalized dengue patients at a particular time. Participant demographics across the studies showed a wide age range, from children under 15 to elderly patients with a mean age of 70, and a varied gender distribution, with male participants comprising 47.4–70.9% of the study populations. Diagnostic methods for confirming dengue infection included NS1 antigen detection, IgM/IgG antibodies by ELISA, and PCR for viral RNA, reflecting standard practices for accurate dengue diagnosis. The criteria for determining AKI among the studies were based on established clinical guidelines such as KDIGO, AKIN, and RIFLE, which rely on changes in serum creatinine levels and urine output. The quality of the studies is given in Table S4 .

Predictors of AKI in dengue

The predictors of AKI in dengue infection identified through meta-analysis are summarized in Table  2 and illustrated in Fig.  2 . Predictors identified from single studies are presented separately in Table  3 ; Fig.  3 .

Predictors of Acute kidney injury among dengue cases based on meta-analysis of multiple studies. Red line indicates effect size and CI of significant predictors. Black line indicates effect size and CI of non-significant predictors. Dotted vertical line indicate point of no effect

Predictors of Acute kidney injury among dengue cases reported by individual studies. Red line indicates effect size and CI of significant predictors. Black line indicates effect size and CI of non-significant predictors. Dotted vertical line indicate point of no effect. Abbreviations: aPTT - Activated Partial Thromboplastin Time, ASR/ALT - Aspartate Aminotransferase/Alanine Aminotransferase, CKD - Chronic Kidney Disease, CNS - Central Nervous System, HBV - Hepatitis B Virus, WBC - White Blood Cell

Demographics

Age was evaluated in five studies, and the analysis yielded an adjusted OR of 1.11 (95% CI: 0.87–1.35), indicating a slight but not statistically significant increase in the risk of AKI with advancing age. The heterogeneity among these studies was reported as 0%, suggesting high consistency in the findings across different research settings. The factor of male sex was also examined in five studies, revealing a more pronounced association with AKI. The adjusted OR was 3.13 (95% CI: 1.82–4.44), indicating that males with dengue are over three times more likely to develop AKI than females, with 0% heterogeneity, underscoring the robustness and reliability of the association across different studies. Obesity or overweight status was explored in three studies as a potential predictor of AKI in dengue patients. The analysis yielded an adjusted OR of 1.4 (95% CI: 0.69–2.18), which suggests a moderate increase in the risk of AKI among obese or overweight individuals. However, this association did not reach statistical significance. Similar to the other demographic factors, the heterogeneity for this predictor was reported as 0%, indicating consistent findings across the included studies.

Comorbidities

Hypertension was assessed in five studies, with the findings indicating an OR of 1.13 (95% CI: 0.34–1.93). This suggests a marginally increased risk of AKI among dengue patients with hypertension, although the wide confidence interval indicates a degree of uncertainty in the exact magnitude of this risk. The heterogeneity for this association was reported as 0%. Diabetes mellitus was analyzed in four studies, revealing a association with AKI in dengue patients. The adjusted OR for this comorbidity was 3.298 (95% CI: 0.274–6.322), indicating that individuals with diabetes mellitus are significantly more likely to develop AKI when suffering from dengue. Despite the wide confidence interval, which suggests variability in the effect size, 0% heterogeneity was noted. Chronic kidney disease (CKD) was examined in a single study, which identified it as a potential risk factor for AKI in dengue patients. The study reported an adjusted OR of 2.2 (95% CI: 0.42–11.24). Although this finding is based on a limited number of studies and the confidence interval is wide, suggesting a high degree of uncertainty, it does indicate a possible increased risk of AKI for dengue patients with pre-existing CKD.

Dengue severity and serotype

Severe forms of dengue, such as DHF and severe dengue, were analyzed across seven studies, highlighting a significant association with an increased risk of AKI. The combined data yielded an OR of 2.22 (95% CI: 1.02–3.42). This indicates that individuals suffering from severe dengue, characterized by more critical symptoms and complications, are over two times more likely to develop AKI compared to those with less severe forms of the disease. The heterogeneity among these studies was remarkably low, at 8%, suggesting a relatively consistent association across different research settings and populations. The analysis of dengue serotype 2 as a specific risk factor for AKI was conducted in a single study, which found high adjusted OR of 6.67 (95% CI: 0.24–98.12). Despite the broad confidence interval, this result indicates a potentially substantial increase in the risk of AKI associated with dengue serotype 2. However, the wide confidence interval and the fact that this finding is based on a single study underscore the need for caution in interpretation and highlight the importance of further research to confirm the role of dengue serotype 2 in the development of AKI.

Co-infections

The role of co-infections in exacerbating the risk of AKI in dengue patients has been explored through the analysis of hepatitis B virus (HBV) co-infection and coexisting bacterial infections. The presence of these co-infections alongside dengue virus infection appears to significantly influence the likelihood of developing AKI, highlighting the complexity of managing patients with multiple concurrent infections. The analysis of HBV co-infection, conducted in a single study, indicated a notable increase in the risk of AKI among dengue patients. The adjusted OR for this co-infection was 3.46 (95% CI: 0.98–12.23). Although the confidence interval suggests some uncertainty in the magnitude of the effect, the point estimate indicates that dengue patients with HBV co-infection are over three times more likely to develop AKI compared to those without HBV co-infection. Coexisting bacterial infection was also identified as a significant risk factor for AKI in dengue patients, based on a single study. The adjusted OR for AKI in the presence of a bacterial infection was strikingly high at 6.15 (95% CI: 2.57–14.74).

Clinical manifestations

Multiple organ involvement has been identified as a significant predictor of AKI, with an OR of 18.04 (95% CI: 8.68–27.4) based on two studies. This indicates a dramatically increased risk of AKI in the presence of multi-organ dysfunction, emphasizing the severity of dengue’s impact on patients. The heterogeneity for this predictor was reported as 0%, indicating consistent findings across studies. Rhabdomyolysis, analyzed in three studies, showed an OR of 4.71 (95% CI: 0.0-9.89), with a heterogeneity of 44%. This suggests a notable association between rhabdomyolysis and AKI risk, although the wide confidence interval indicates uncertainty in the precise effect size. Respiratory distress and hematuria were each analyzed in single studies, showing ORs of 4.15 (95% CI: 1.79–9.63) and 2.12 (95% CI: 1.14–3.95), respectively. These findings suggest that both respiratory distress and hematuria are associated with an increased risk of AKI in dengue patients. Major bleeding was another significant predictor, with a single study reporting an OR of 9.12 (95% CI: 2.33–34.12), indicating a substantial increase in AKI risk in the context of severe bleeding events. Extremely elevated liver enzymes, indicated by ASR/ALT levels greater than 1000 IU/L, were reported to potentially double the risk of AKI, with an adjusted OR of 2.4, although the wide confidence interval of 0.1–59.3 signals significant uncertainty in this estimate. Similarly, elevated creatine kinase levels above 190 U/L, indicative of muscle breakdown, were linked to a substantially increased risk of AKI, with an OR of 11.7 (95% CI: 1.1-122.4), reflecting considerable variability. Direct evidence of liver involvement in dengue showed a marginal association with AKI risk (OR of 1.03), but the extremely broad confidence interval (0.02-279.37) highlights the uncertainty surrounding this association. An elevated International Normalized Ratio (INR), signaling coagulation abnormalities, was associated with a significant increase in AKI risk (OR of 6.44), suggesting that patients with coagulopathy are at heightened risk. The Apache II score, a measure of disease severity, also indicated that higher severity scores correlate with increased AKI risk (OR of 3.00), emphasizing the link between disease severity and kidney injury. Low white blood cell counts, specifically initial WBC less than 3.0 × 10^3/mm^3, suggested an increased risk of AKI (OR of 4.67), pointing to the impact of significant leukopenia on kidney health. High hemoglobin concentrations, potentially indicative of hemoconcentration, showed a possible but uncertain increase in AKI risk (OR of 2.8), while prolonged activated partial thromboplastin time (aPTT) was mildly associated with an increased risk of AKI (OR of 1.81). Central nervous system involvement in dengue was linked to a significant increase in the risk of developing AKI, with an OR of 12.08, highlighting the severe implications of CNS complications.

Nephrotoxic drugs

The use of nephrotoxic drugs among dengue patients has been identified as a significant factor associated with an increased risk of AKI, based on an analysis of four studies. The combined data from these studies yielded an adjusted OR of 2.26 (95% CI: 1.24 – 3.27). This finding indicates that patients with dengue who are exposed to nephrotoxic drugs are more than twice as likely to develop AKI compared to those not exposed to such medications.

Delayed hospitalization and length of hospital stay

Delayed hospitalization, analyzed in two studies, showed an adjusted OR of 2.14 with a 95% CI ranging from 1.04 to 3.25. This indicates that patients with dengue who experience delays in receiving hospital care are over twice as likely to develop AKI compared to those who are hospitalized promptly. The implication is clear: timely access to medical care is crucial for minimizing the risk of severe complications such as AKI in dengue infection. The length of hospital stay specifically stays longer than three days, was examined in a single study and found to be associated with an increased risk of AKI, with an OR of 3.07 (CI: 1.68–5.62). This suggests that patients with dengue requiring prolonged hospitalization are significantly more likely to suffer from AKI, possibly reflecting the severity of their condition or complications arising during their care.

This is the first systematic review and meta-analysis to assess the predictors of AKI in dengue patients, highlighting critical insights into the complexity of managing dengue infections, particularly concerning AKI development. Our findings reveal a multifaceted interaction of demographic, clinical, and laboratory factors significantly influencing AKI risk among dengue patients. The analysis identified several key predictors and risk factors for AKI development, including CKD, severe forms of dengue, rhabdomyolysis, respiratory distress, hematuria, major bleeding, elevated ASR/ALT levels, liver involvement, an elevated International Normalized Ratio, Apache II scores, initial WBC, hemoglobin concentrations, prolonged aPTT, CNS involvement, and a length of hospital stay > 3 days. However, only a few studies were available for some of these predictors, and the populations varied across studies, with some focusing on children and others on adults. Similarly, the criteria used for AKI diagnosis varied among the studies. Due to the limited number of studies for some outcomes, we could not perform a publication bias analysis.

The association of AKI with demographic factors such as age and male gender, as well as with certain comorbidities including diabetes mellitus and chronic kidney disease, underscores the need for a targeted approach in the clinical management of dengue. Particularly, the strong association between male gender and AKI risk may reflect underlying biological differences or perhaps differences in exposure or health-seeking behavior between genders. The significant link between diabetes mellitus and AKI risk highlights the importance of managing metabolic conditions as part of comprehensive dengue care. the findings regarding the association of AKI with severe forms of dengue and certain clinical manifestations, such as rhabdomyolysis, respiratory distress, and major bleeding, emphasize the critical nature of these conditions and the necessity for early recognition and intervention. These factors not only serve as markers of disease severity but also as potential triggers for the development of AKI, suggesting that aggressive management of severe dengue may help mitigate the risk of AKI. The observed relationship between nephrotoxic drugs and AKI risk in dengue patients also warrants attention. This finding calls for cautious use of medications in the management of dengue, especially in settings where patients may already be at increased risk of kidney injury. Clinicians must balance the need for specific treatments against the potential harm, emphasizing the need for vigilant monitoring and adjustment of drug therapies in this patient population.

A previous systematic review assessed the prevalence of AKI in dengue patients, synthesizing data from 37 studies and involving 21,764 participants with dengue [ 5 ]. This analysis found an overall AKI prevalence of 8%. Focusing on gender, the review included findings from seven studies that reported data separately for male and female patients. It revealed that AKI was more prevalent among males (17%) compared to females (3%). The authors suggest that this disparity indicates a higher susceptibility to AKI in males, potentially due to the role of testosterone in promoting renal tubular cell inflammation and fibrosis, a mechanism that animal studies have supported.

The studies included in our analysis employed varying definitions of AKI, which may significantly impact the interpretation and generalizability of our findings. The criteria used across the studies included the RIFLE criteria, the AKIN criteria, and the KDIGO guidelines. Each of these frameworks has distinct thresholds for diagnosing AKI, based on changes in serum creatinine levels and urine output. This lack of uniformity in defining AKI could lead to discrepancies in the reported incidence and identified risk factors, making it difficult to compare results across studies and potentially introducing bias into the pooled estimates. Therefore, while our meta-analysis offers valuable insights into the predictors of AKI in dengue patients, the findings should be interpreted with caution.

Our review has several implications for clinical practice. It indicates the importance of early identification and aggressive management of dengue patients with high-risk profiles for AKI. This includes not only those with severe dengue but also patients presenting with specific risk factors such as advanced age, male gender, existing comorbidities like diabetes mellitus and CKD, and clinical manifestations indicative of multi-organ involvement. the findings highlight the need for clinicians to exercise caution when prescribing nephrotoxic drugs to dengue patients, advocating for the monitoring of renal function and the use of alternative treatments where feasible. Additionally, the association of delayed hospitalization with increased AKI risk emphasizes the importance of timely medical intervention, suggesting that public health measures should aim to reduce barriers to healthcare access and encourage early hospital presentation for dengue patients. This review identifies several areas for future research, including the need for studies that explore the mechanisms underlying the association between dengue infection and AKI, the role of genetic and environmental factors in influencing AKI risk, and the effectiveness of specific interventions to prevent AKI in this population. Furthermore, research should aim to standardize the diagnostic criteria for AKI in the context of dengue to facilitate more accurate assessments and comparisons across studies. our findings reinforce the need for strategies to prevent dengue infection and its complications, including vector control measures, public education campaigns, and the development of effective vaccines. Moreover, healthcare systems in dengue-endemic areas should be strengthened to improve the early detection and management of dengue and its complications, including AKI.

Integrating demographic, clinical, and laboratory data helps stratify patient risk and tailor interventions, aligning with the World Health Organization’s (WHO) sustainable development goal of healthy lives and promoting well-being for all ages by reducing disease and mortality rates [ 25 ]. Recognizing the complex contributors to AKI in dengue patients enables healthcare providers to enhance early detection, monitoring, and management strategies. Ultimately, these efforts aim to alleviate the burden of AKI on patients and healthcare systems.

Our study has several limitations. We only included published datasets, potentially overlooking relevant unpublished data or studies in the gray literature. Some predictors were reported in only a single study, limiting the ability to generalize findings across different populations and settings. We could not statistically assess the presence of publication bias due to the limited number of studies for some outcomes, which may influence the reliability of our results. The variables adjusted for in the calculation of ORs varied among the studies, introducing variability in risk estimates. There is heterogeneity among the populations studied, particularly in terms of age differences, which could affect the applicability of the findings to broader demographics. This heterogeneity underscores the need for cautious interpretation of our results and suggests that future research should aim to include a more diverse and comprehensive dataset to validate our findings and enhance our understanding of AKI predictors in dengue patients. Studies which evaluate the association of each of these factors are required in future.

Our analysis provides crucial insights into the predictors of AKI among dengue patients, highlighting the multifaceted nature of risk factors ranging from demographic and clinical profiles to specific dengue virus serotypes and co-infections. The findings reinforce the importance of early identification and targeted management of high-risk individuals to mitigate the development of AKI, which can significantly worsen patient outcomes. Future research should focus on studying each of these factors and aim to standardize AKI diagnostic criteria within the context of dengue to enhance the accuracy and generalizability of the results.

Data availability

All data are presented within the manuscript and are available by contacting the corresponding author.

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Acknowledgements

The authors acknowledge the Nested-Knowledge, MN, USA for providing the access to the software.

Open access funding provided by The Science, Technology & Innovation Funding Authority (STDF) in cooperation with The Egyptian Knowledge Bank (EKB).

Author information

Abdelaziz A. Awad, Mahalaqua Nazli Khatib equallly contributed and first authors.

Authors and Affiliations

Faculty of Medicine, Azhar university, Cairo, Egypt

Abdelaziz A. Awad

Division of Evidence Synthesis, Global Consortium of Public Health and Research, Datta Meghe Institute of Higher Education, Wardha, India

Mahalaqua Nazli Khatib

Jawaharlal Nehru Medical College, and Global Health Academy, School of Epidemiology and Public Health, Datta Meghe Institute of Higher Education, Wardha, India

Abhay M Gaidhane

Department of Chemistry and Biochemistry, School of Sciences, JAIN (Deemed to be University), Bangalore, Karnataka, India

Suhas Ballal

Department of Allied Healthcare and Sciences, Vivekananda Global University, Jaipur, 303012, Rajasthan, India

Pooja Bansal

Department of Endocrinology, NIMS University, Jaipur, India

Manish Srivastava

Chandigarh Pharmacy College, Chandigarh Group of College, Jhanjeri, Mohali, 140307, Punjab, India

Department of Chemistry, Raghu Engineering College, Visakhapatnam, 531162, Andhra Pradesh, India

M Ravi Kumar

School of Applied and Life Sciences, Division of Research and Innovation, Uttaranchal University, Dehradun, India

Aashna Sinha

Department of Biotechnology, Graphic Era (Deemed to be University), Clement Town, Dehradun, 248002, India

Pramod Rawat

Department of Allied Sciences, Graphic Era Hill University Clement Town, Dehradun, 248002, India

Department of Paediatrics, Hospital and Research Centre, Dr. D. Y. Patil Medical College, Dr. D. Y. Patil Vidyapeeth, Pune, 411018, Maharashtra, India

Department of Public Health Dentistry, Dr. D.Y. Patil Dental College and Hospital, Dr. D.Y. Patil Vidyapeeth, Pune, 411018, Maharashtra, India

Center for Global Health Research, Saveetha Institute of Medical and Technical Sciences, Saveetha Medical College and Hospital, Saveetha University, Chennai, India

Ganesh Bushi

School of Pharmaceutical Sciences, Lovely Professional University, Phagwara, India

Sorabh Lakhanpal

University Center for Research and Development, Chandigarh University, Mohali, Punjab, India

Muhammed Shabil

Medical Laboratories Techniques Department, AL-Mustaqbal University, Hillah, Babil, 51001, Iraq

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Substantial contribution to the conception or design of the work: Muhammed Shabil, Mahalaqua Nazli KhatibAcquisition of data: Manish Srivastava, Suhas Ballal, Pooja BansalAnalysis and interpretation of data for the work: Isha Arora, M Ravi Kumar, Aashna Sinha, Pramod RawatDrafting the work: Aashna Sinha, Sorabh LakhanpalRevising it critically for important intellectual content: Muhammed Shabil, Pooja Bansal, Suhas Ballal, M Ravi KumarResources: Manish Srivastava, Pramod Rawat, Ganesh BushiFinal approval of the version to be published: All authors (Abdelaziz A. Awad, Mahalaqua Nazli Khatib, Abhay M Gaidhane, Suhas Ballal, Pooja Bansal, Manish Srivastava, Isha Arora, M Ravi Kumar, Aashna Sinha, Pramod Rawat, Sanjit Sah, Ganesh Bushi, Sorabh Lakhanpal, Muhammed Shabil)Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved: All authors (Abdelaziz A. Awad, Mahalaqua Nazli Khatib, Abhay M Gaidhane, Suhas Ballal, Pooja Bansal, Manish Srivastava, Isha Arora, M Ravi Kumar, Aashna Sinha, Pramod Rawat, Sanjit Sah, Ganesh Bushi, Sorabh Lakhanpal, Muhammed Shabil).

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Awad, A.A., Khatib, M.N., Gaidhane, A.M. et al. Predictors of acute kidney injury in dengue patients: a systematic review and meta-analysis. Virol J 21 , 223 (2024). https://doi.org/10.1186/s12985-024-02488-7

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Patient Satisfaction with Healthcare Services and the Techniques Used for its Assessment: A Systematic Literature Review and a Bibliometric Analysis

Diogo cunha ferreira.

1 Centre for Public Administration and Public Policies, Institute of Social and Political Sciences, Universidade de Lisboa, Rua Almerindo Lessa, 1300-663 Lisbon, Portugal

2 CERIS, Instituto Superior Técnico, University of Lisbon, Av. Rovisco Pais 1, 1049-001 Lisbon, Portugal

Inês Vieira

3 Instituto Superior Técnico, University of Lisbon, Av. Rovisco Pais 1, 1049-001 Lisbon, Portugal

Maria Isabel Pedro

4 CEGIST, Instituto Superior Técnico, University of Lisbon, Av. Rovisco Pais 1, 1049-001 Lisbon, Portugal

Paulo Caldas

5 Business and Economic School, Instituto Superior de Gestão, Av. Mal. Craveiro Lopes 2A, 1700-284 Lisbon, Portugal

6 Centre for Local Government, UNE School of Business, University of New England, Armidale, NSW 2350, Australia

Miguel Varela

7 CEFAGE, Faculdade de Economia, Universidade do Algarve, Campus of Gambelas, 8005-139 Faro, Portugal

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Patient satisfaction with healthcare provision services and the factors influencing it are be-coming the main focus of many scientific studies. Assuring the quality of the provided services is essential for the fulfillment of patients’ expectations and needs. Thus, this systematic review seeks to find the determinants of patient satisfaction in a global setting. We perform an analysis to evaluate the collected literature and to fulfill the literature gap of bibliometric analysis within this theme. This review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) approach. We conducted our database search in Scopus, Web of Science, and PubMed in June 2022. Studies from 2000–2021 that followed the inclusion and exclusion criteria and that were written in English were included in the sample. We ended up with 157 articles to review. A co-citation and bibliographic coupling analysis were employed to find the most relevant sources, authors, and documents. We divided the factors influencing patient satisfaction into criteria and explanatory variables. Medical care, communication with the patient, and patient’s age are among the most critical factors for researchers. The bibliometric analysis revealed the countries, institutions, documents, authors, and sources most productive and significant in patient satisfaction.

1. Introduction

Healthcare systems are continually changing and improving, and so it is necessary to find a way to assess outputs while evaluating the satisfaction of the service receiver, in this case, the patient. One can define patient satisfaction as a patient’s reaction to several aspects of their service experience. Assessing patient satisfaction may provide valuable and unique insights about daily hospital care and quality. One widely accepts it as an independent dimension of care quality that includes internal aspects of hospital care. Patient satisfaction is a concept that has long been neglected and cast aside, but is becoming gradually more important. Donabedian [ 1 ] includes it as an outcome of healthcare services; hence, it is of utmost importance to evaluate care quality. Several authors argue that satisfaction and the result in terms of the patient’s health status are related terms [ 2 , 3 , 4 , 5 ]. Thus, the present study sheds light on the factors that most influence patient satisfaction. With this information, managers can more efficiently allocate resources to improve patients’ experience and satisfaction [ 6 ].

Measuring healthcare quality and satisfaction constitutes an indispensable element for adequate resource management and allows for the focus on its users’ preferences, giving them a chance to construct a customized health service, better fitted to their needs and expectations [ 7 ]. When talking about public hospitals, there may not be a financial interest in performing these studies since they are not particularly interested in profit. However, with the increase in market competitiveness, private companies need to meet patients’ needs, satisfying them so that they then become loyal to the organization [ 8 ]. Patient satisfaction can be useful for structuring evaluations referring to patient judgments according to inpatient care. It is relevant from an organizational management perspective [ 9 ]. Patient satisfaction and quality of health services are, thus, crucial elements for the long-term success of health institutions [ 10 ].

Despite the high number of studies regarding this topic, the results are inconclusive and differ across each document [ 11 , 12 , 13 ]. Contradicting evidence exists across patient satisfaction studies due to its subjective nature [ 14 ]. Since each individual has his/her perceptions, satisfaction is nothing but a relative concept, influenced by individual expectations and evaluations of health services’ attributes [ 15 ].

Several systematic reviews have analyzed the determinants of patient satisfaction: Naidu [ 16 ], Almeida et al. [ 17 ], Farzianpour et al. [ 18 ], and Batbaatar et al. [ 14 ] are some noteworthy recent reviews. Similarly, reviews on the methods most utilized by researchers are scarce, and none of them delivers a comprehensive and profound analysis of literature through bibliometric tools. Thus, this analysis aims to assess the different aspects of patient satisfaction in a global healthcare context, along with the identification of the main countries, institutions, documents, authors, and journals of this research area, with co-citation and bibliographic coupling networks. This systematic review can contribute to the knowledge of patient satisfaction, whether the influential factors, or the most advised methodology, and be an essential input for researchers or scholars interested in the study of patient satisfaction. In addition, we conducted a meta-analysis by statistically analyzing the main factors underlying patient satisfaction and the main methodologies adopted for its study.

The incessant demand for improved results and quality of health services offered is of extreme importance in developing a more effective organizational policy adjusted to the patients’ needs. Health organizations recognize that service quality is especially pertinent regarding the healthcare market’s promotion and public image [ 19 ]. Hence, patient satisfaction surfaces as a variable for promoting health organizations’ quality, allowing an assessment and identification of patients’ most relevant dimensions and their satisfaction level. Patient satisfaction helps to measure the quality of healthcare, thus becoming an essential and frequently used indicator. It affects clinical outcomes, medical malpractice claims, and timely, efficient, and patient-centered healthcare delivery [ 20 ]. Patient satisfaction and quality of health services are a priority for the services industry due to increasing consumption and are critical elements for health institutions’ long-term success [ 10 , 21 ].

Even though satisfaction is an essential aspect of quality, the relationship between these two concepts is not linear. On the one hand, satisfaction studies’ results can be ambiguous and may not always be impartial. Given that patients evaluate physicians’ performance, most missing the necessary abilities, results can be based on affinity and not on the health professional’s technical skills. On the other hand, providers may have to face a trade-off between providing satisfaction to their patients or better treatment outcomes [ 22 ]. Since each person has his/her perceptions, satisfaction is nothing but a relative concept, influenced by individual expectations and evaluations of health services’ attributes [ 15 ]. Patient satisfaction is complex to assess, given its multidimensionality. It is composed of diverse aspects that may not be related to the patient’s service’s actual quality.

It is valuable to consider the highly cited Donabedian framework on how to examine health services’ quality in order to surpass the current lack of clarity on defining and measuring satisfaction, and to evaluate the quality of medical care using three components [ 1 , 23 , 24 , 25 ]—structure, process, and outcome (results):

• - Structure: Environment, provider’s skills, and administrative systems where healthcare occurs;
• - Process: The constituents of the received care (measures doctors and medical staff considered to deliver proper service); and
• - Outcome: The result of the care provided, such as recovery, avoidable readmission, and survival;

The conceptualization of patient satisfaction regarding expectations and perceptions is related to Donabedian’s triad. For instance, the patient will be satisfied with hospital attributes if his/her expectations are met [ 25 ]. However, one of the leading criticisms of patient satisfaction ratings is the incapacity to rationalize medical care expectations, which can be affected by previous healthcare experiences [ 26 ]. The same happens with the other two components. The patient will be satisfied with the process if symptoms are reduced. The outcome will be favorable if there is a recovery, demonstrating that received care perception meets prior expectations. Throughout his framework, Donabedian regarded “outcome” as the most crucial aspect, defining it as a change in a patient’s current and future health status that can be confidently attributed to antecedent care [ 22 ].

2. Materials and Methods: Data Collection and Extraction Method

We performed this research respecting the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. A checklist of 27 parameters, including the title, abstract, methods, results, discussion, and funding was taken into consideration to ensure the complete reporting of systematic reviews. PRISMA assures that authors prepare a transparent and complete reporting of systematic reviews and meta-analyses [ 27 ]. The PRISMA statement starts with identifying possible studies to include in our further revision after searching in several databases. We searched papers in the Scopus, Web of Science, and PubMed databases during June 2022. After testing several keywords, the search strategy used the term “patient satisfaction” to extend the number of results. Reference lists from the collected articles were also searched for additional articles. Overall, one thousand six hundred fifty-three studies composed the list of our first search.

Once we concluded our search, we removed the duplicates (241), and the remaining documents (1412) were analyzed under the inclusion and exclusion criteria. Inclusion criteria included: articles from peer-review journals; written in English; published from January 2000 to December 2021; assessed which factors affect patient satisfaction (or a proxy of it); evaluated overall patient satisfaction with healthcare; quantitative studies; reviews; and international studies to provide a more comprehensive analysis. We also excluded reports, books or book chapters, conference proceedings, dissertations, theses, expert opinion, commentaries, editorials, and letters. We excluded 1197 studies from the list after removing duplicates because they failed all inclusion criteria or met at least one exclusion criterion.

We conducted a full-text analysis to assess the eligibility of the remaining 215 papers. Disease-centered studies that did not evaluate the general aspects of patient satisfaction were excluded. We also discarded papers with unclear data collection methods, papers with unclear results, and qualitative papers. We rejected a total of 58 papers in this step.

Figure 1 outlines the PRISMA diagram detailing the study selection process. Following such a statement, 157 studies met the inclusion criteria. Four of them were systematic reviews, and the remaining 153 apply quantitative methods for patient satisfaction analysis.

PRISMA statement.

3. Past Research on Patient Satisfaction: What Did the Systematic Reviews Tell Us about It?

The first systematic review [ 16 ] included a study of twenty-four articles published between 1978 and 2006. Through the analysis of these articles, health care output, access, caring, communication, and tangibles were the dimensions determining patient satisfaction. The patient’s socio-demographic characteristics that affected satisfaction were age, education, health status, race, marital status, and social class. SERVQUAL (service quality) was the most preferred instrument in satisfaction studies. In their review, the authors developed a conceptual model, claiming that healthcare quality and determinants influence patient satisfaction, influencing patient loyalty.

The second systematic review [ 17 ] included thirty-seven international articles from 2002 to 2013. Patient-professional interactions, the physical environment, and internal management processes were the most influential satisfaction constructs, except for specific services, such as home care, psychiatric or pediatric services. Almeida et al. disregarded patient’s socio-demographic characteristics from their review. In this type of service, phone contact and provided information were also considered powerful satisfaction constructs. The primary methodology used in the collected articles was factor analysis (exploratory factorial analysis (EFA) and confirmatory factor analysis (CFA)).

The third systematic review [ 14 ] comprised one hundred and nine international articles from 1980 to 2014. This study identified nine determinants of satisfaction: technical skills, interpersonal care, physical environment, accessibility, availability, finances, organizational characteristics, continuity of care, and care outcome. Technical skills constitute a cluster of medical care, nursing care, friendliness, concern, empathy, kindness, courtesy, and respect. The physical environment results from the atmosphere, room comfort, bedding, cleanliness, temperature, lighting, food, comfort, equipment, facilities, and parking. Accessibility is composed of location, waiting time, the admission process, the discharge process, and the effort to get an appointment. Availability represents the number of doctors, nurses, facilities, and equipment. Meanwhile, finances include the flexibility of payments, the status of insurance, and insurance coverage. Organization characteristics include reputation, image, administrative processes, doctors’ and nurses’ satisfaction level, and doctors’ socio-demographic characteristics. The authors found thirteen patient socio-demographic characteristics in their review: patient age, gender, education, socio-economic status, marital status, race, religion, geographic characteristics, visit regularity, length of stay, health status, personality, and expectations. The relationship between patient satisfaction and these socio-demographic characteristics was contradictory across the articles; thus, the authors achieved no conclusions. The most used methodology from the articles’ collection was not mentioned in the review.

Finally, the fourth and most recent systematic review [ 28 ] includes only thirty-eight international articles from 2000 to 2017. Provider’s attitudes, technical competence, accessibility, and efficacy were found to be the most influential attributes in this study. Provider’s attitudes comprise courtesy, friendliness, kindness, approachability, respect, responsiveness, attention, and concern. Accessibility also consists of a cluster of attributes, including the location, environment, equipment availability, appointment arrangement, and access equitability. Expectations, patient’s socio-demographic characteristics, and market competition were considered as antecedents to satisfaction while influencing it. There is no mention of the methods most used by the articles collected.

These four systematic reviews analyzed multiple articles to find the determinants of patient satisfaction. The gathered results and conclusions show coherence between the reviews. However, we can identify some limitations. The sample size of some reviews is somehow insufficient to achieve reliable conclusions. The methodology present in the articles collected should be studied more deeply to determine the different methodologies used in patient satisfaction studies and their advantages and disadvantages.

4. Results and Discussion

4.1. a summary of quantitative papers passing the prisma sieve.

After searching for quantitative papers within the patient satisfaction field, we constructed a table containing the most relevant data retrieved from them: author names, published year, country of study, sample size, satisfaction dimensions and drivers (if applicable), methodology, dependent variable, main factors affecting patient satisfaction, number of citations, and publisher. We considered a dependent variable field because, besides overall patient satisfaction, some articles studied proxies of satisfaction, such as willingness to recommend the hospital or willingness to return. Table 1 contains an excerpt of the articles with more than 100 citations (a total of 19 studies).

Review of collected articles.

Table 2 and Table 3 present statistical measures applied to the data collected. The sample size, the first object of analysis, shows a significant coefficient of variance due to the values’ dispersion, as shown through the minimum and maximum rows in both analyses. In Table 2 , the dispersion is more significant, with a higher coefficient of variation. The study with the most significant sample size in the first analysis is McFarland et al. [ 45 ], which analyzed 3907 private hospitals. For the second analysis, Aiken et al. [ 12 ] has the largest sample size.

Statistical measures applied to all collected data.

Statistical measures applied to the articles with more than 100 citations.

Regarding the methodology used, most studies applied only one method. However, some studies used two methods in a complementary way. The number of criteria used to assess patient satisfaction has a low variance. Researchers give more importance to criteria than to explanatory variables through the values present in these tables. The number of criteria has a higher mean, median, and mode, meaning that researchers tend to disregard the vital aspect of satisfaction drivers. The main difference between both analyses is the minimum and the maximum number of criteria applied in the studies. Table 2 shows a minimum of zero and a maximum of 26, meaning that studies only assessed the importance of explanatory variables. However, in Table 3 , the minimum is one, showing that studies with higher citations do not solely evaluate explanatory variables. The maximum number of criteria is also distinct in both tables, with a decrease of ten units in Table 3 . Explanatory variables have a 100% coefficient of variance, with equal mean and standard deviation on both analyses. The number of critical factors has low variance, and the minimum is equal to one because each study seeks to fix the determinants of patient satisfaction. On the one hand, in Table 2 , the number of citations presents a more dispersed pattern with a higher difference from the minimum to the maximum value. Over 20 years, it is reasonable to collect articles with an exact number of citations. On the other hand, Table 3 , showing only articles with more than 100 citations, presents a more cohesive dataset.

4.2. Statistical Analysis over the Utilization and Importance of Satisfaction Criteria and Explanatory Variables

Factors related to satisfaction can be either criteria or explanatory variables. The assessment of hospital service quality can be a complicated task that includes numerous criteria, qualitative and dubious factors that are difficult to assess [ 46 ].

From the collected papers, we analyzed each factor’s utilization related to patient satisfaction. We also verified the importance rate of each factor. The percentage of utilization is the ratio between the number of studies using it is and the total number of evaluated studies, while the importance rate of a factor measures the relative number of papers concluding that this factor is critical for patient satisfaction.

In general, studies about patient satisfaction try to unveil factors associated with his/her overall satisfaction with one or more services (96% of the collected studies) or willingness to recommend the hospital/clinic (9%) instead. A smaller percentage of studies (7%) included both dependent variables [ 12 , 40 , 47 , 48 , 49 , 50 , 51 , 52 ]. There is one dependent variable (typically the overall satisfaction) explained by a series of criteria and other external factors. However, one can also use other dependent dimensions as proxies for such overall satisfaction. Examples include the willingness to return [ 36 , 48 , 53 ], medical services satisfaction, accommodations services satisfaction, nursing services satisfaction [ 54 ], satisfaction with the quality of medical information [ 55 ], and healthcare quality [ 56 ]. Compared with the overall satisfaction and the willingness to recommend hospitals/clinics, other studies are scarce within the sample of papers passing the PRISMA sieve. Therefore, we conducted three different analyses because of the different dependent variables used in each article, i.e., global analysis regardless of the dependent variable used, overall patient satisfaction, and willingness to recommend a hospital/clinic.

To provide a more unambiguous graphic representation of the analysis, we grouped some patient satisfaction related factors related to each other into a single factor. These are some examples: (i) concern (from the doctor, the nurse, or other staff, either clinical or not); (ii) clinical staff social characteristics (assurance, attention, attitudes, kindness, skills, and specialty); (iii) hospital characteristics (image, location, quality, size, and type); and (iv) patient’s social characteristics (autonomy, dignity, emotional support, income, life expectancy, marital status, nationality, occupation, race, residence, satisfaction with life, and stress level).

4.2.1. Global Analysis about the Most Frequently Used Satisfaction Criteria and Explanatory Variables

We started by analyzing all factors related to patient satisfaction, clustering in terms of satisfaction criteria and explanatory variables, regardless of the dependent variable used by researchers. As their name indicates, explanatory variables are useful to find out potential drivers or determinants for satisfaction. They are nondiscretionary for hospital/clinic managers but may play a prominent role in infrastructure management. We divided the fifteen most utilized factors into criteria and explanatory variables; Figure 2 and Figure 3 represent them, respectively. These factors are the ones that most researchers use to study patient satisfaction and may not correspond to the most important and influential factors of patient satisfaction.

Analysis of the most utilized criteria in the literature (global analysis).

Analysis of the most utilized explanatory variables in the literature (global analysis).

Of the fifteen most used factors, eleven are criteria, and four are explanatory variables. The doctor’s characteristics, waiting time, medical care, and information provided have the highest utilization rates of utilization within the criteria. Patient’s social characteristics, patient’s age, patient’s education, and perceived health status also have the highest utilization rate, but are within the explanatory variables. However, this analysis is not directly related to the importance rate analysis; thus, the most utilized factors might not be the most important and influential.

Figure 4 ranks the criteria deemed as the most important to evaluate satisfaction. In contrast, Figure 5 presents the most critical explanatory nondiscretionary dimensions. This first analysis, the most complete one, resulted in fifty-six factors, divided into forty-seven criteria and nine explanatory variables. From Figure 4 , it is possible to conclude that the three criteria most important in collecting articles are medical care, waiting time, and communication with the patient. Despite not being in the top three, criteria related to the doctor’s social skills exhibit a high importance rate and should be noticed. It is interesting to note that researchers conclude that staff’s social skills, such as communication, are more critical than others, such as like food quality and comfort. Also, the criteria associated with the technical skills of staff appear to be less critical. This seems to be in line with some authors who claim that patients are usually unable to judge health professionals in those terms [ 2 , 3 , 4 , 5 ].

Analysis of criteria deemed as the most critical in the literature (global analysis).

Analysis of explanatory variables deemed as the most critical in the literature (global analysis).

Additionally, waiting time is one of the most critical criteria to study patient satisfaction. For instance, Ferreira et al. [ 25 ] classified this criterion as a critical must-have requirement. It means that patients take it for granted and neither get satisfied nor dissatisfied if the waiting time is null. However, their dissatisfaction increases intensely when waiting time becomes more substantial. The authors also verified that waiting time was the most crucial criterion for patients in medical appointment services.

Figure 5 shows that the patient’s age, the perceived health status, and the patient’s education are the variables that studies tend to consider as the most influential to patient satisfaction. Previous studies that say that age, education, and self-reported health status have an evident and significant influence on the satisfaction outcomes were confirmed [ 38 ]. Older patients or those with better self-perceived health status are typically more satisfied, while highly educated people are less satisfied with the healthcare services provided [ 34 , 42 ].

Differences arise after comparing the results from the utilization analysis and the importance rate analysis. Figure 2 and Figure 4 , both portraying criteria, reflect differences in the ranking positions. The doctor’s characteristics, the most utilized criterion, was placed fourth on the importance-related raking. Communication with the patient also occupies different positions in the analysis. Figure 2 shows this criterion in the seventh position, while in Figure 4 , it is the third criterion with the highest importance rate.

Regarding the explanatory variables, Figure 3 and Figure 5 also display disparities. The patient’s social characteristics are the most used cluster of explanatory variables, but it occupies the fourth position on the importance rate analysis. The patient’s age has the second-highest utilization rate and the highest importance rate. The patient’s education occupies the third position in both analyses. Lastly, perceived health status is ranked fourth in Figure 3 , but secondly in Figure 5 .

4.2.2. Overall Patient Satisfaction as the Dependent Variable

As in the previous case, we divided our analysis into criteria and explanatory variables. Identical to the global analysis, the fifteen factors deemed the most used in literature are eleven criteria and four explanatory variables. The results of this analysis are equal to the global analysis’ results, with a slight change in the percentage level. The doctor’s characteristics, waiting time, medical care, and information provided remain the most used criteria with a percentage of 43%, 38%, 28%, and 27% each. The four explanatory variables continue the same, with the patient’s characteristics, patient’s age, patient’s education, and perceived health status as the most utilized. The percentages of these variables suffered minor modifications.

Regarding the importance analysis, fifty-six factors are assessed, similar to the first analysis, with forty-seven criteria and nine explanatory variables. One can only observe a few differences between this and the previous analyses. It is mostly motivated by the fact that researchers often tend to look at the overall satisfaction instead of other related concepts like willingness to return or recommending the healthcare provider. The three most important criteria are medical care, waiting time, and communication with the patient. These are the same as the first analysis, but with a modification of each criterion’s percentages. As mentioned above, the doctor’s social skills also have a similar percentage as the top three global analysis criteria. However, in this second analysis, the criterion “accommodations” has a higher utilization percentage. The patient’s age, perceived health status, and patient education are the most important explanatory variables. The variables are the same as in Figure 5 but have different percentages.

4.2.3. The Willingness to Recommend the Healthcare Provider as the Dependent Variable

The third and last analysis regards the dependent variable “willingness to recommend.” For the utilization analysis, we also present the fifteen most used factors. However, since one sole factor is an explanatory variable (patient’s characteristics), both criteria and explanatory variables are presented on the same chart ( Figure 6 ).

Analysis of the most utilized factors in the literature (willingness to recommend analysis).

The results of this utilization analysis differ from the two utilization analyses presented above. Despite doctor’s and patient’s characteristics being the factors with the highest utilization rates (consistent with the previous analysis), the remaining factors and percentages suffered alterations. Waiting time and medical care, the second and third criteria with the highest utilization rates on the previous analyses, are now positioned in seventh and eighth place, respectively. Nurses’ characteristics and nursing care are the criteria with the most significant rate increase, at more than 30%. The change in the dependent variable is responsible for the alterations of these results. Studies that consider the dependent variable “willingness to recommend” tend to adopt different factors, focusing on nursing care and professionals, compared with the studies analyzing the “overall patient satisfaction.”

In the importance analysis, since there were only twenty factors assessed, including nineteen criteria, and only one explanatory variable, we show the results compiled in Figure 7 . Regarding the explanatory variables, only the patient’s age resulted from our search. It is a consistent result compared to the previous ones, given that the patient’s age is the most relevant explanatory variable in all three analyses. As one can see, the three most important criteria are waiting time, nursing care, and the doctor’s social skills. Medical care, the most frequent criteria in the other two analyses, is not as relevant in this analysis. Nursing care is more relevant in this analysis than in the previous ones. It is in line with the results of the utilization analysis for this dependent variable. Nursing related factors are more frequent and deemed crucial when the dependent variable is “willingness to recommend.”

Analysis of factors deemed as the most critical in the literature (willingness to recommend analysis).

4.3. Discussion on the Most Critical Patient Satisfaction Criteria and Explanatory Variables

When comparing the results from the three analyses carried out, it is possible to reach conclusions about each factor’s importance. According to the literature, the criteria of medical care, communication with the patient, and waiting time are the three most critical. The doctor’s social skills, accommodations, nursing care, and information provided can also be considered relevant criteria. The explanatory variables of patient’s age, perceived health status, and patient’s education are the remaining ones.

Some past systematic reviews have revealed that interpersonal or social skills (such as medical/nursing care and attitudes), technical skills, infrastructure and amenities, accommodations, environment, accessibility, continuity of care, and the outcome are the satisfaction criteria present in the majority of studies related to satisfaction in healthcare [ 14 , 16 , 17 , 18 ]. In terms of explanatory variables, these reviews also point out the frequent use of variables such as the patient’s gender, age, education, and marital status. These dimensions should affect customers’ satisfaction ratings, helping to understand them, but should not be confused with criteria.

Despite the similarity of results between the previous reviews and the current one, some other factors seem to assume a high relevance for researchers. They include waiting time and the information provided, which interestingly are not present in the previous reviews. On the one hand, waiting time is a determinant of healthcare dissatisfaction, regardless of the inpatient stage. Waiting time is clearly an obstacle to access. Meanwhile, efficient hospitals usually have short waiting times [ 15 ]. The longer the waiting time, the more dissatisfied the customer is [ 57 ]. However, the converse is not necessarily true. If the waiting time is very short or even null, the customer may take it for granted because she/he needs the medical/nursing procedure and be neither satisfied nor dissatisfied. It means that waiting time is usually pointed out as a must-have requirement [ 25 ].

On the other hand, the criterion information provided may refer to any care process, since the patient enters the system until he/she leaves it. Communication or the capacity of providing useful information includes the treatment guidelines, rights, duties, means of complaint and suggestions, current health status, and the post-discharge process at home. For instance, inadequate post-discharge care and lack of patients’ preparedness are two potential determinants of readmissions for further care [ 58 ]. Readmissions within a specific (short) period after discharge may reveal a lack of care appropriateness, either in terms of the clinical staff’s technical skills or the information provided about care at home. Therefore, it is an excellent practice to sufficiently prepare the discharged patient (or someone responsible for her/him) for proper care at home. Missing or confusing information provided by the clinical staff contributes to a lack of preparedness and, by consequence, to customer dissatisfaction. We should remark that communication should be a social skill of any healthcare worker. The fact that this criterion does not appear in previous reviews is perhaps the result of merging some criteria related to it. However, we point out the need for high discrimination of criteria during a satisfaction survey.

4.4. Methods Employed in the Literature

Figure 8 provides a chart comparing the different literature methods devoted to the patient’s satisfaction analysis. We identified four main methods: logistic regression analysis, factor analysis, structural equation modeling (SEM), and multiutility satisfaction analysis (MUSA). Nonetheless, other ancillary methods are suitable for satisfaction analysis when complementing those four.

Analysis of methods utilized in the literature.

We can observe that regression analysis is chosen by most researchers (64%). Factor analysis is in second place, with 24% utilization, followed by SEM (11%), and lastly MUSA (1%). From the 153 collected articles, 27 (18%) combined different methods in a complementary nature: factor analysis with regression analysis (16 of the 27 articles, or 59%), and factor analysis with SEM (11 of the 27 articles, or 41%), are the two combinations observed. The difference in the level of utilization of each method can be due to the difficulty of implementation. SEM and MUSA are more complex than the other two and thus harder to implement. Contrary to this, logistic regression and factor analysis are more straightforward to implement, becoming more attractive to the researcher. We provide a brief description of each method below to better understand the methodology used in the articles collected.

Factor analysis: A mathematical model explains the correlation between a broad set of variables in terms of a small number of underlying factors [ 59 ]. It uses procedures that summarize information included in a data matrix, replacing original variables with a small number of composite variables or factors [ 60 ].

Logistic regression analysis: This analysis is frequently employed to model the association between a response and potential explanatory variables. Every association is evaluated in terms of an odds ratio [ 61 ].

Structural Equation Modelling (SEM): This is a general modeling technique used to test the validity of theoretical models that define causal and hypothetical relations between variables [ 62 , 63 ]. Some researchers have combined SEM with other types of analyses for the study of satisfaction, although without an application to the case of healthcare, such as with Ciavolino et al. [ 64 ] and Sarnacchiaro et al. [ 65 ].

Multicriteria Satisfaction Analysis (MUSA): The basic principle of MUSA is the aggregation of individual judgments into a collective value function, assuming that customers’ global satisfaction depends on a set of criteria representing service characteristic dimensions [ 25 , 66 ]. MUSA has a generalization, called MUSA-INT [ 67 ], which accounts for positive and negative interactions among criteria.

4.5. Discussion on the Most Frequent Model/Method Used in Literature

As seen in Figure 8 , the most used method is logistic regression analysis due to its implementation simplicity and reliability of results. Logistic regression is a statistical method where one variable is explained or understood based on one or more variables. The variable being explained (typically the overall satisfaction or the willingness to return) is the dependent or response variable. The other variables used to explain or predict the response are the independent variables. Essential features of logistic regression include: (a) it provides a single regression coefficient estimate of covariates for each response category; (b) it follows stochastic ordering; (c) it is easy and straightforward to apply; (d) it needs a few parameters to estimate; and (e) the odds are proportional across the response variable are [ 71 , 72 ]. The outcome variable in an ordinal logistic regression model can have more than two levels. An estimation of the probability of being at or beneath an outcome level, depending on the explanatory variable, is executed in this analysis [ 73 ]. Limitations are, however, also a part of this model, since: (a) large samples are required since the coefficients are estimated by maximum likelihood estimate; (b) proportional odds assumption should be satisfied, meaning that the odds ratio is constant across the cut-off point for each of the covariates in the model. If this assumption is not truthful, the estimate of the parameters obtained is not valid [ 71 ].

Another alternative for categorical variables is MUSA [ 66 ]. This model can be applied to the satisfaction-related data [ 74 , 75 , 76 ] because it estimates (through optimization) the value functions associated with each criterion and value scales are no longer categorical. Unlikely logistic regressions, MUSA does not rely on the proportional odds assumption that rarely is satisfied in practice. In truth, MUSA is a model for satisfaction analysis, which is nothing but a robust ordinal regression. For that reason, we may argue that MUSA is the non-parametric version of logistic regression and, therefore, makes fewer assumptions than the latter. In other words, while some validity conditions must be met so that the result of parametric models is reliable, non-parametric models can be applied regardless of these conditions. However, the power of the parametric model is traditionally superior to the power of its non-parametric counterpart. Furthermore, MUSA is challenging to implement, limiting its use by more researchers. We should point out that it is good practice to apply several alternative models (namely MUSA and the logistic regression) and to test for the robustness of outcomes.

Other approaches have also been proposed in the literature to study satisfaction. One is the so-called Benefit of Doubt model [ 77 ], which is a particular case of the well-known Data Envelopment Analysis (DEA). Bulut [ 78 ] used the Benefit of Doubt to construct a composite index based on citizens’ emotions and senses. Such an alternative was not applied to the healthcare sector at that point in time. However, Löthgren and Tambour [ 79 ], Bayraktar et al. [ 80 ], Gok and Sezen [ 81 ], Mitropoulos et al. [ 82 ], and Mohanty and Kumar [ 83 ], to name a few, have included satisfaction data in their DEA exercise. The same critique made to the use of ordinal data in SEM and PCA applies to the case of the Benefit of Doubt (and DEA), as it is nothing but a linear programming model. The Benefit of Doubt is commonly used for benchmarking purposes. If one wishes to benchmark decision-making units based on satisfaction, one can couple MUSA and Doubt’s benefit. Indeed, recalling Grigoroudis and Siskos [ 66 ] and Ferreira et al. [ 25 ], one can establish a satisfaction index associated with each criterion and decision-making unit. Such an index is a function of the utilities per satisfaction level. Therefore, these indexes can replace the indicators traditionally used in the Benefit of Doubt model. Another alternative is the DEA-based maxmin model of Li et al. [ 84 ], Dong et al. [ 85 ], and Wu et al. [ 86 ] that allows the maximization of each decision-making unit’s satisfaction.

The principal component logistic regression is another alternative recently proposed. According to Lucadamo et al. [ 87 ], Labovitz [ 88 ] and O’Brien [ 89 ], “ proved that if the number of categories is sufficiently large (e.g., six or seven points), one can apply the product-moment correlations on ordinal variables with negligible bias .” However, such conclusions resulted from controlled simulation procedures, which might hardly apply to the real world. Although the logistic regression has its own merits regarding the analysis of satisfaction determinants, it also has limitations, as discussed above. Unless “ successive categories of the ordinal variables are equally spaced ” (an extreme assumption), then the merging of PCA and logistic regression is not likely to produce reliable results.

The multiobjective interval programming model proposed by Marcenaro-Gutierrez et al. [ 90 ] and Henriques et al. [ 91 , 92 ] which was applied to explore the trade-offs among different aspects of job satisfaction is an interesting one. In short, the model optimizes some coefficients related to those trade-offs by merging interval programming and econometric techniques. It should be explored in the future and applied to the healthcare sector.

4.6. Is There Any Association between the Adopted Method and the Criteria Deemed More Critical for Satisfaction Analysis?

To corroborate or invalidate the hypothesis of an association between adopted methods and critical factors, an analysis was performed where the critical factors mentioned per study were clustered in terms of the method adopted. As demonstrated above, the main critical factors are waiting time, medical care, communication with the patient, information provided, and patient’s age. Logically, these factors are the most prominent in each method, given their high importance rate.

From the logistic regression analysis, waiting time, patient’s age, communication with the patient, doctor’s characteristics, and medical care are the factors with the most notable presence. In factor analysis, doctor’s characteristics, medical care, waiting time, the information provided, and accommodations are the most relevant factors. Using SEM, accommodations and doctor’s characteristics are the more noticeable factors. Finally, with MUSA, accommodations, waiting time, doctor’s characteristics, and admission process are the most distinguishing factors. However, due to the reduced number of studies applying this latter method, it was not possible to assess any pattern of association between this method and the critical factors.

Assessing the analysis results, it is possible to conclude that most factors with a consistent presence within the different methods are critical factors. Thus, we found no association pattern between the most critical factors and the researcher’s method.

4.7. Is There Any Association between the Country and the Critical Factors?

To examine a possible relationship between the country of study and the critical factors, an analysis was performed on the five countries with the highest number of studies. This restriction was applied because of the reduced number of studies per country and the inability to reach conclusions with a reduced number of studies. The USA, the country with a higher number of studies, revealed that patients’ most critical factors are doctor’s characteristics, patient characteristics, waiting time, and patient’s age. In Germany, doctor’s characteristics, organization, outcome, and medical care are the most critical factors. Chinese patients consider medical expenditure and doctor’s characteristics to be the two most important factors. In Portugal, accommodations, waiting time, accessibility, and medical care are deemed the most critical factors. Finally, in Turkey, doctors’ and nurses’ characteristics and waiting time are the most critical factors for the patients.

It is possible that factors diverge from country to country, giving insight into patients’ preferences from different parts of the world [ 93 ]. The doctor’s social skills are the most important for most countries, followed by waiting time and medical care.

5. Bibliometric Analysis

Bibliometric analysis is a separate analysis that one can apply to evaluate research by analyzing bibliographic data and describing publication patterns within a determined field. Methods such as co-citation and bibliographic coupling, which are discussed below, can be considered relational techniques to explore research structure, indicating patterns of authors or affiliations and prominent topics or methods [ 94 , 95 ]. The number of articles included in this bibliometric analysis differs from the number included in the statistical analysis. For the collection of articles, the databases Scopus, Web of Science, and PubMed, as already mentioned, were all explored. However, when performing a bibliometric analysis, it was not possible to compile the citation files of different databases. Thus, to achieve and extract the maximum information possible, we choose the Scopus citation file as the one with the highest potential to perform the bibliometric analysis in the Bibliometrix R package software. The citation files have different sizes, the Scopus database being the one with the highest number of articles included, 140. Web of Science included 118, and PubMed only included eight articles. It is important to note that the same article can be present in more than one database.

Figure 9 presents the growth rate of the number of published articles and mean total citations (TC) in the collection. It can be observed that these two variables are not aligned with each other, meaning that when one grows, the other does not necessarily grow as well. In the years 2009, 2010, and 2011, the number of published articles peaked, with a percentage of 6%, 7%, and 9%, respectively. The number of publications then decreased and peaked in 2018, 2019, and 2020. The mean of TC reached peaks in 2000, 2011, 2002, and 2012, and thus was not directly related to the number of publications. Neither of these variables follows a linear path, since the inflation occurs in what seems to be random intervals of time.

Number of articles and mean of total citations (TC) per year.

In this collection of 140 articles, 100 journals served as sources. The ten journals displayed in Table 4 are the ones with the highest number of publications (in this collection) and alone represent 42% of the articles. Most of the journals are related to health, as would be expected, but patient satisfaction is multidisciplinary. Despite many articles related to health, business, social sciences, and biochemistry, there are examples of subject areas in which this topic is included. When comparing the number of TC for each journal with the articles in this collection, Social Science & Medicine is the journal where the highest cited articles are published.

Ten of the most utilized journals. The citations presented in this table are the sum of the total citations of the articles published by each journal.

In total, there is a reach of 57 countries in this review. However, only the ten countries with more publications are presented in Table 5 . It is noticeable that most of the articles collected are from the USA. Germany, China, and Portugal also have a particular emphasis, being the countries with the highest number of publications. It is important to note that many publications have affiliations with more than one country. Among the ten most impactful institutions, four are from the USA, and the remaining are also from countries mentioned in Table 5 .

Ten most studied countries from collected articles.

5.1. Co-Citation Analysis

A co-citation analysis measures the frequency of two publications cited together, indicating the affinity and proximity between them [ 96 ], and can also be applied to authors and sources. Two documents are co-cited when a third document cites them; having more documents that cite the same two documents translates into a more robust association [ 95 ]. This analysis says that two co-cited papers have a similar theme [ 94 ], thus identifying the most influential authors and their interrelationships inside a determined theme [ 97 ]. The co-cited papers are grouped into different clusters, considering the research area’s knowledge base and the similarity of themes [ 98 ]. The results of the top fifteen publications are presented in Table 6 .

Total citations (TC) and TC/year of the fifteen most cited publications.

Table 6 provides a citation analysis to identify the most influential articles on the subject of patient satisfaction. In addition to the total number of citations, the number of average citations per year is also included in this analysis, given that it provides an unbiased look at the impact of each article without prioritizing the year of publication [ 99 , 100 ]. When analyzing Table 6 , it is possible to conclude that the article with the highest number of citations is the most impactful and influential in the collection. The same happens for the following four articles. An example of an article with a ratio of TC/Year that is relatively high for the number of TC is Bjertnaes et al. [ 43 ], ranked on the second to last table position.

5.1.1. Documents’ Co-Citation Analysis Results

Figure 10 shows the network of the co-citation analysis (the graphs are constructed through VOSviewer software). Circles represent the items (documents, authors, sources, or keywords). The higher the number of citations or occurrences, the larger the size of the circle. Not all items are displayed; otherwise, they might overlap. The path length estimates the distance between items; the closer two items are, the stronger their relatedness. The connections between the items (lines) are called links. Link strength is a number associated with the link itself, which shows how secure the connection is between the items assessed. For instance, in the co-authorship links, the higher the link strength, the higher the number of publications the two authors developed [ 101 , 102 ].

Documents’ co-citation analysis network using VOSviewer software. Source: authors’ own construction.

Through association strength and considering publications with a minimum of seven citations, 32 articles within four clusters were found. It is important to note that the citations considered are local citations.

Cluster 1 comprises ten articles and is the second most cited cluster, with 102 citations and the most important regarding link strength (566). The studies included in this cluster are from the USA and are mainly reviews or academic settings. The main article within this cluster is Sitzia and Wood [ 103 ] with 24 citations and a 133-link strength. This cluster has the oldest set of collected articles, all ranging from the 1980s to the 1990s.

Cluster 2 is a collection of nine articles, with 103 citations and 485 link strength. Overall, it is the cluster with the highest number of citations but the second in link strength. These studies are all from the USA and create more profound research since they explore what factors influence patient satisfaction by developing patient surveys. The articles with the most impact in this cluster are Jackson et al. [ 11 ] with 18 citations and 94 link strength, and Jaipul and Rosenthal [ 104 ], with ten citations and 62 link strength. The majority of articles presented in this cluster are from dates after the 2000s.

Cluster 3 , in its turn, is composed of eight articles, with a total of 57 citations and 218-link strength. This cluster has the lowest number of citations and is the second to last regarding link strength. The articles focus on finding the factors that influence patient satisfaction, but are not as in-depth as the second cluster articles. Some articles with an academic setting are also present. The most important articles in this cluster are Andaleeb [ 32 ] with nine citations and 31 link strength; Parasuraman et al. [ 105 ], with nine citations and 23 link strength; and Otani et al. [ 106 ], with eight citations and 44 link strength.

Cluster 4 has five articles, with a total of 249 citations and 50 link strength. Regarding citations, this cluster is ranked in third place. It is the least important in terms of link strength. The articles from this cluster are all from the 1980s and 1990s, similar to the first cluster. Hall et al. [ 107 ], with 18 citations and 104 link strength, Cleary and McNeil [ 108 ] with nine citations and 39 link strength, and Kane et al. [ 109 ] with eight citations and 37 link strength, are the articles with the most impact in this cluster.

5.1.2. Authors’ Co-Citation Analysis Results

There are 8691 authors; thus, a restriction of a minimum of 20 citations per author was applied, and 30 authors were found divided into four clusters. Figure 11 shows the network of the author’s co-citation when the method of association strength is applied. The circles’ size represents the number of times the author is cited in the collection of 140 articles.

Authors’ co-citation analysis network using VOSviewer software. Source: authors’ own construction.

Cluster 1 includes fourteen authors and is the most crucial cluster, with the highest number of citations (449) and link strength (4775). The most relevant authors are Cleary (54 citations and 581 link strength), Hall (50 citations and 466 link strength), and Kroenke (45 citations and 535 link strength). These authors correspond to cluster 4 of Figure 10 , highlighting two of the above mentioned as the authors of two of the most cited documents of cluster 4 on the documents’ co-citation analysis.

Cluster 2 includes seven authors and is placed second on ranking the number of citations (213) and link strength (2147). Otani is the most relevant author in this cluster (50 citations and 485 link strength). This author is also the one with the most contributions to the collection, with a total of six articles, followed by Elliott (34 citations and 243 link strength) and Kurz (29 citations and 337 link strength), who collaborates with Otani on four of the six articles present in the database. Some of these authors have articles present on cluster 3 of the co-citation analysis.

Cluster 3 has five authors and placed third with regard to citation’ ranking (125) and link strength (969). Parasuraman (31 citations and 228 link strength), Donabedian (29 citations and 275 link strength), and Zeithaml (25 citations and 205 link strength) are the most influential authors in this cluster. The authors of this cluster are dispersed through clusters 3 and 4 of the documents’ co-citation analysis.

Cluster 4 is composed of four articles and is the least relevant cluster in citations (99) and link strength (823). The authors in this cluster are Aiken (31 citations and 236 link strength), Orav (25 citations and 185 link strength), Sloane (22 citations and 199 link strength), and Coulter (21 citations and 203 link strength). These authors are not present in Figure 11 due to the low number of local citations of their articles.

5.1.3. Sources’ Co-Citation Analysis Results

In Figure 12 , sources (journals) where the articles were published are assessed to find the frequency in which two sources are co-cited. It translates into the similarity between the scope of focus of the sources. Each circle represents a journal, and the size of the circle is proportional to the number of citations. Sources in the same cluster or that are connected have similarities.

Sources’ co-citation analysis network using VOSviewer software. Source: authors’ own construction.

From the 2278 sources present in the sample’s references, only sources with more than 20 citations were considered, making up a total of 29 sources. Through the method of normalization strength, three clusters were found. It is important to note that the sources in this analysis are the sources of documents cited by the collection of 140 articles and not the sources from the 140 articles in the collection.

Cluster 1 is composed of ten items and is the least important in citations (303) and link strength (4879). Despite being one of the most significant clusters, the sources included are not the most renowned. The International Journal of Health Care Quality Assurance (47 citations and 614 link strength), The Healthcare Manager (41 citations, and 496 link strength), and The Journal of Marketing (40 citations and 767 link strength) are the most relevant journals in this cluster. Cluster 1 is the only cluster of the analysis that included sources not only related to the medical field, such as the Journal of Marketing , Journal of Retailing, Journal of Services Marketing, Journal of the Academy of Marketing Science , and Managing Service Quality .

Cluster 2 has ten items and is the most important regarding citations (660) and link strength (9719), as can be seen by the differential size of the circles in Figure 12 . Social Science & Medicine (189 citations, and 2632 link strength), Medical Care (179 citations and 2450 link strength), and The Journal of General Internal Medicine (73 citations and 1217 link strength) are the most important sources regarding citations’ link strength in this cluster. Special attention goes to The British Medical Journal, Annals of Internal Medicine , and The Journal of the American Medical Association , which are the sources with a significant impact on the field. It is noticeable that the second cluster is the most important and impactful of the three.

Cluster 3 included nine sources and is in second place in citations (400) and link strength (4890). The International Journal for Quality in Health Care (86 citations and 995 link strength), BMC Health Services Research (59 citations and 683 link strength), and Health Services Research (56 citations and 756 link strength) are the sources with the most citations and link strength in this cluster. It is necessary to give a particular highlight to other sources integrated into this cluster, such as The New England Journal of Medicine and The Lancet , two highly influential journals in medicine.

5.2. Discussion on the Bibliometric Analysis Results

After conducting a bibliometric study with co-citation and bibliographic coupling analysis, it is possible to assess the changes and constants on patients’ satisfaction studies throughout the years and the most influential articles, authors, and journals in the field. The research topic is constant throughout the years, discovering the factors that influence patient satisfaction, those being explanatory variables or criteria that remain in focus. Being that this a worldwide study, articles from multiple countries and institutions were analyzed. However, the USA is the country with the highest number of published articles in this field and the largest number of institutions that executed the research. From a collection of 140 articles, 39% are from the USA, followed by China and Germany, with 8% each. The discrepancy between the number of articles in the USA and the remaining countries might be a result of their health system. Since most facilities are for-profit organizations, it is imperative to keep the customers (patients) satisfied, secure their loyalty, and, thus, ensure the organization’s success. Profitable loyalty and satisfaction need to be taken to a higher level where differentiation and competitive advantage are met [ 110 ].

As mentioned above, with bibliometric methods, it is possible to assess which articles, authors, and journals are the most important in the subject area. Combining the results from both co-citations and bibliographic coupling analysis ensures that a large number of items are evaluated and that definitive conclusions can be achieved.

For the co-citations and bibliographic coupling analysis of articles, the top five documents, considering citations and link strength are: Patient satisfaction: A review of issues and concepts by Sitzia and Wood [ 103 ], Predictors of patient Satisfaction by Jackson et al. (2001), Patient sociodemographic characteristics as predictors of satisfaction with medical care: A meta-analysis by Hall and Dornan [ 111 ], Patients’ experiences and satisfaction with health care: results of a questionnaire study of specific aspects of care by Jenkinson et al. (2002), and Service quality perception and patient satisfaction: A study of hospitals in a developing country , by Andaleeb [ 32 ]. From the decades of 1990 and 2000, these documents are the most influential with regard to the topic of patient satisfaction. It is important to note that from Table 6 , the document Patient safety, satisfaction, and quality of hospital care: Cross-sectional surveys of nurses and patients in 12 countries in Europe and the United States from Aiken et al. [ 12 ], is the article with the most citations, as well as the most influential article throughout the years. However, it was not included in the co-citation nor the bibliographic coupling analysis because it had no connection with the other articles, and thus zero link strength.

The authors’ co-citation and bibliographic coupling analysis revealed that the five most influential authors regarding citations and link strength are Cleary, Hall, Otani, Sjetne, and Aiken. Even though these authors do not have articles presented above that are mentioned as the most influential, these authors have written multiple articles on patient satisfaction and are thus essential and influential in the field.

The sources’ co-citation and bibliographic coupling analysis show that in terms of citations and link strength, Social Science & Medicine and Medical Care are the two most prestigious journals. The International Journal for Quality in Health Care, The Journal of General Internal Medicine , and The Journal of the American Medical Association are also influential journals in patient satisfaction.

6. Concluding Remarks and Future Directions for Research

This study reviewed studies published between 2000 and 2021 in three databases regarding patient satisfaction determinants. Firstly, a statistical analysis to discover the factors that influence patient satisfaction and the researchers’ methods was performed. Secondly, we executed a bibliometric analysis to find the most influential authors and documents within this theme.

The statistical analysis results yielded multiple determinants of satisfaction within diverse research areas, such as medicine, business, and the social sciences. Medical care, communication with the patient, and waiting time, patient’s age, perceived health status, and patient’s education are the factors that most influence patient satisfaction. Each one of these factors can create a positive or negative experience for the patient. Patient satisfaction directly connects to the loyalty of the patient towards the healthcare provider. Patient loyalty results in positive behaviors such as healthcare providers’ recommendations, compliance, and higher healthcare service usage, thus increasing profitability. With healthcare becoming an increasingly competitive market, measuring healthcare satisfaction and quality can help managers control, improve, and optimize several organizational aspects. While some markets and industries try to improve customer orientation, healthcare practitioners have to remain alert for the modifying behaviors of patient expectations [ 10 , 16 , 28 , 112 ]. An important market arising in the past few years has been that of medical tourism, and Ghasemi et al. [ 113 ] have comprehensively studied the impact of cost and quality management in patient satisfaction in this market. The authors verified the existence of a relationship of these three dimensions. Therefore, it becomes obvious that cost impacts satisfaction, a topic that has been overlooked by many researchers. Additionally, social media has been deemed as a relevant way for customers to express their satisfaction levels [ 114 , 115 , 116 ]. The influence of this route on the results should be better understood in future research.

The importance of the determinants of patient satisfaction can be assessed through several methods, as has been previously seen. Due to the ease of handling and computation, factor and regression analyses are the healthcare management methods. However, despite MUSA’s low usage rate, this is a useful method, with many advantages over the traditional customer satisfaction models. It considers the customers’ judgments in the way they are expressed in the questionnaires [ 25 , 67 ]. One must be careful when using ordinal data within models that are not suitable for the former; however, a lesson from our research is that some researchers are still struggling with those models despite the mathematical objections that these face. MUSA’s low usage in healthcare and its potential compared with other alternatives creates opportunities for broader dissemination of studies using that model. Other theoretically suitable alternatives should also be highlighted, including MUSA-INT, the integrated use of MUSA (or MUSA-INT) alongside benchmarking techniques (like DEA or the Benefit of Doubt), and some useful and appropriate multiobjective interval programming models.

Of course, the highlighted fact that patient satisfaction and health quality are not linearly related, and that the patient cannot always properly assess the provider’s performance, is a limitation that any satisfaction-based study faces. Despite the obvious need to study satisfaction determinants (and several reviews have tried to deal with this issue), the consistency of results is somehow absent. Perhaps the socio-economic differences among patients and even the characteristics of the health care systems in which they are part of may help to explain this lack of consistency. Future research should focus on this matter. Another possible limitation is the fact that we did not distinguish between inpatients and outpatients in this study. Although satisfaction may depend on the service itself, the same patient can be either an inpatient or an outpatient in different moments, meaning that the next experience (as an outpatient) will be somehow biased by the previous one (as an inpatient or vice-versa). It may help to justify the fact that often the term “patient satisfaction” seems more appropriate to study the healthcare facility as a whole, as it was one of the objectives in this study.

With regard to the second part of this study, an analysis of the literature through bibliographic methods featured the most important aspects of patient satisfaction research. Based on the article’s co-citation analysis, Patient satisfaction: A review of issues and concepts by Sitzia and Wood was the most relevant document. The published date of this article is 1997; thus, it was not included in our collection. However, when the reference list of the sample articles was analyzed, it was present on most of the lists. From the bibliographic coupling analysis, Predictors of Patient Satisfaction by Jackson et al. was the most critical document. This document was published in 2001, and thus it was included in our collection. These two articles are considered the most important and impactful in the area of patient satisfaction. The author’s co-citation and bibliographic coupling analysis revealed that Cleary and Otani are two of the most influential authors in this field. Both authors have collaborated in many articles in this research area; they are, thus, considered to be two of the most relevant researchers. Cleary’s articles related to patient satisfaction were published in the 1990s and are not included in our collection. Otani, however, is the author with the most documents in our collection. Despite the fact that his number of citations is not the highest, this author is influential because of the high number of collaborations in the field. From the journal’s co-citation and bibliographic coupling analysis, Social Science & Medicine and Medical Care were the most influential in patient satisfaction. However, considering general medicine/health, these journals were not the ones with the highest impact.

The knowledge obtained from this systematic review can be seen as an essential foundation for additional studies, and can be used to enhance further knowledge among healthcare practitioners, researchers, and scholars.

Funding Statement

This research received no external funding.

Author Contributions

Conceptualization, D.C.F. and M.I.P.; methodology, I.V.; software, I.V.; validation, D.C.F., P.C. and M.V.; formal analysis, I.V. and M.I.P.; investigation, D.C.F. and I.V.; resources, D.C.F. and I.V.; data curation, I.V.; writing—original draft preparation, D.C.F. and I.V.; writing—review and editing, D.C.F., M.I.P., P.C. and M.V.; visualization, M.V.; supervision, M.I.P.; project administration, D.C.F.; funding acquisition, D.C.F. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

Informed consent statement, data availability statement, conflicts of interest.

The authors declare that they have no conflict of interest.

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