Managing patient expectations through understanding health service experiences

Benedetta Crisafulli, Mohammad Wasil, Jaywant Singh, Sabine Benoit

Introduction

The continuous growth in patient numbers and needs poses several challenges for medical professionals and support staff within the National Health Service (NHS).¹ Health care services are under financial strain in the light of the changing demographic structure of the UK population that requires improved access to health services. Managing patient satisfaction represents another major challenge. Evidence from a recent national survey in the UK shoes that dissatisfaction with the NHS has increased by seven percentage points in 2017, reaching 29 percent, its highest level since 2007.² Staff shortages, long waiting times for surgical operations and access to care, inadequate funding, and slow-paced government reforms are among the reasons for dissatisfaction. For hospitals, long waiting times at the A&E department, and delays for patients in need of critical care represent major concerns.³

Unsatisfactory health care service experiences generate negative outcomes for health service providers in terms of managing patients’ experience of care, and meeting performance targets. As patients are ultimately the receivers of health care provision, understanding their experiences of care is pivotal.⁴ The psychological processes underlying patients’ perceptions and evaluations of service provided by the health care professionals, play a crucial role in patient satisfaction. The cognitive processes of patients and their support network, such as friends and relatives, influence perceptions and attitudes towards health care treatment and service. Research underpinned by knowledge from social psychology can shed light on such cognitive processes and generate insights for effective management of patient satisfaction.

The concept of psychological threat in health care service experiences can be explained through the notion of ‘lock-in situations’⁵ perceived by the patients. For instance, when visiting a hospital or a GP surgery, patients often undertake externally-imposed activities, such as long waiting time for a doctor’s appointment, ease of self-service check-in, lack of acuity in self-care and monitoring, and/or unsatisfactory interactions with support staff – all parts of the service provision. Such situations can be perceived as a threat to the self-determination needs, such as the need for autonomy. Patients who regularly use health care services in the UK associate four main types of threat to health care service experiences, in response to which coping strategies are activated. We discuss these below.

Perceived threats associated with health care services

Patients who use health care services in the UK often report situations they find threatening or questioning their astuteness and sense of control. Interactions with health care staff can make patients feel unintelligent and/or incompetent and restricted in personal control. This is typical of encounters where healthcare support staff are unable to address patients’ queries accurately, and their attempt at resolving the issue is perceived subconsciously as unnecessary and inappropriate by the patients. The above seems to be due to a general lack of trust in the competence of health care personnel, and more conspicuously the perception that they were not willing to act in the interest of patients. Poor health status at the time of accessing health care services might also hinder patients’ willingness to accept advice from health care professionals. Such experiences of threat to self-competence are often associated with negative or even vengeful behavior towards the health service provider, which is the party perceived as threatening. The psychological mechanism behind such behavior is that retaliation alleviates the emotional discomfort caused by threat perceptions⁶.

Threats to personal control are often reported when processes in the health care service provision are perceived as inadequate and lead to, for instance, long waiting times for appointment booking and/or rescheduling. Our qualitative research show that patients perceive the process of booking a doctor’s appointment as ‘a nightmare’, ‘particularly time-consuming’ and ‘complicated’. They perceive a loss of control when seeking to book or reschedule an appointment. When appointments are not scheduled around their commitments, patients perceive that they are not being heard.

Furthermore, health care service experiences are perceived as threatening to the individual’s self-esteem; especially in situations where patients feel ignored by the health care personnel, and their own self-esteem and social identity are being undermined. A key reason is the perceived lack of empathy and concern of health care personnel during interactions with patients.

How patients activate coping strategies

The lock-in situations discussed above can affect satisfaction and well-being, despite patients’ general compliance with requests from health care personnel.⁵ Social psychology research shows that perceived threats, such as those reported in health care service experiences, increase feelings of anxiety, averseness, lack of control, and aggressiveness.⁶ Crucially, in response to threats and consequent negative feelings, patients activate coping strategyas a mechanism of self-defense. We postulate that coping strategies, in turn, influence their behavior, aimed at compensating for the unsatisfactory experience⁷. Such behaviour can be negative, and at times even vindictive towards the health care service provider.

Social psychology research distinguishes between individual’s coping strategies⁸ aimed at addressing the source of the threat (i.e. problem-focused coping), and those focused on re-establishing positive emotions, for instance through the act of venting dissatisfaction caused by the threat (i.e. emotion-focused coping). In health care services, patients often seek to proactively react to threats, thereby engaging in problem-solving. This is especially the case when unsatisfactory health care service experiences are aggravated by a serious illness. Severity of the illness markedly influences patients’ willingness to take actions in response to threats. Crucially, the decision to act seems to benefit patients, as they report feeling ‘back in control of the situation’ – a form of compensatory behaviour⁹. Cerebral activities, such as rational and positive thinking, influence the extent to which patients confront threats. Rational thinkingcan induce patients to take a step back from the experience, reconsider the factors at play, and plan their next actions.

Crucially, in the process of coping with threats imposed by health service experiences, patients often feel overwhelmed. Negative emotions in such threatening circumstances are heightened, and the support from their network of friends and family appears to be fundamental. Intriguingly, for some patients, social media is increasingly seen as a useful source of emotional support, which appears to be gradually replacing conventional forms of verbal, face-to-face support.

Final remarks

We offer an overview on how insights from social science research can be valuable for informing decision-making of health care service providers. This is especially the case in decisions related to staff hiring, training and development, service process improvement and supporting systems design. Lack of empathy and concern from frontline health care staff, outdated service processes and systems represent threats to patients. An implication is that innovative training of frontline staff is necessary for the development of soft skills, which are highly valued by patients. Developing caring and supportive relationships between health care personnel and patients is necessary, as these have considerable bearing on the outcome of healthcare service experiences. Similarly, introducing the practice of simulating patients’ care experience can help to identify threats whilst introducing service improvements and innovations. There is also need for health care service providers to be aware of the fact that patients’ health status at the time of seeking access to and experiencing health services influences their evaluations of the quality of care and of the service experience. It follows that the service provision needs to be adapted to account for patients’ health status and vary according to different patients’ groups. Insights from social science research can inform practice for enhanced provision of health care services. Further survey-based research focusing on the causal links between psychological threat, coping and patient well-being¹⁰ is on hand.

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