The purpose of this assignment is to observe and reflect on psychosocial nursing communication with a focus on end-of-life care as well as interprofessional communication and collabor

224  |  Nursing Open. 2018;5:224–232.wileyonlinelibrary.com/journal/nop2

1  | INTRODUC TION

Countless number of encounters occur in healthcare organizations every day. Encounter is a concept related to the words meeting, ap- pointment or relationship but diverges as the encounter regularly means more a personal contact between a few people that takes place planned or unplanned, that come across and get in touch with each other (Westin, 2008). Some healthcare encounters are short and temporary while others are long- lasting and recurring. Short and temporary healthcare encounters between patients and caregivers require more things to be taken care of in a short pe- riod of time (Holopainen, Nyström, & Kasén, 2014). Lack of time in healthcare encounters can therefore be an obstacle to the develop- ment of a caring relationship, as they require a high level of quality

communication between the patients and the professionals (Nåden & Eriksson, 2002).

To ensure a good healthcare encounter, there must be sufficient time for communication, enough resources and opportunities for patients and professionals to create a meaningful relationship, re- gardless of the duration of the encounter (Nygren Zotterman, Skär, Olsson, & Söderberg, 2015). From the patient’s perspective, a mean- ingful relationship is often described as individualized attention fo- cusing on his or her needs (Attree, 2001) that allows him or her to be involved in the decision- making process (Covington, 2005). A good and meaningful relationship, from the patient’s perspective, is char- acterized by gratitude and trust (Gustafsson, Gustafsson, & Snellman, 2013). This is in line with a person- centred perspective, which im- plies working towards an integration of “being with,” the relational

Received: 23 October 2017  |  Accepted: 25 January 2018

DOI: 10.1002/nop2.132

R E S E A R C H A R T I C L E

Patients’ complaints regarding healthcare encounters and communication

Lisa Skär1  | Siv Söderberg2

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited. © 2018 The Authors. Nursing Open published by John Wiley & Sons Ltd.

1Department of Health, Blekinge Institute of Technology, Karlskrona, Sweden 2Department of Nursing Sciences, Mid Sweden University, Östersund, Sweden

Correspondence Lisa Skär, Department of Health, Blekinge Institute of Technology, Karlskrona, Sweden. Email: [email protected]

Abstract Aim: To explore patient- reported complaints regarding communication and health- care encounters and how these were responded to by healthcare professionals. Design: A retrospective and descriptive design was used in a County Council in northern part of Sweden. Both quantitative and qualitative methods were used. Methods: The content of 587 patient- reported complaints was included in the study. Descriptive statistical analysis and a deductive content analysis were used to investi- gate the content in the patient- reported complaints. Results: The results show that patients’ dissatisfaction with encounters and commu- nication concerned all departments in the healthcare organization. Patients were most dissatisfied when they were not met in a professional manner. There were dif- ferences between genders, where women reported more complaints regarding their dissatisfaction with encounters and communication compared with men. Many of the answers on the patient- reported complaints lack a personal apology and some of the patients failed to receive an answer to their complaints.

K E Y W O R D S

communication, nurse–patient relationship, patient advisory committee, patient complaints, quality of health care

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part and “doing for,” the task- based part of nursing (McCormack & McCane, 2010). Person- centred care has been shown to have a significant impact on patient and caregiver interactions, health out- comes and patient satisfaction with care (Ekman et al., 2011). Since an encounter takes place between unique persons and in a moment of mutual recognition, no person can know how the other is going to experience an interaction due to the interpretive nature of inter- action (Nåden & Eriksson, 2002). Therefore, is it important to focus on communication and healthcare encounters between patients and healthcare professionals.

1.1 | Background

Patient- reported complaints showing that most complaints are around communication and interaction with healthcare profes- sionals (Montini, Noble, & Stelfox, 2008). Patient- reported com- plaints about healthcare encounters are an increasing issue (Cave & Dacre, 1999; Friele, Kruikemeier, Rademaker, & Lawyer, 2013; Kline, Willness, & Ghali, 2008; Wessel, Lynøe, & Helgesson, 2012), despite an increased focus on patient – centred care (Skålen, Nordgren, & Annerbäck, 2016). The number of patients who reported complaints about Swedish health care more than doubled between 2007–2013 (Activity report Patients’ Advisory Committee 2014). From an inter- national perspective, patients’ complaints about healthcare encoun- ters are increasingly recognized in, for example, Germany (Schnitzer, Kuhlmey, Adolph, Holzhausen, & Schenk, 2012), United Kingdom (Lloyd- Bostock & Mulcahy, 1994; Nettleton & Harding, 1994), USA (Garbutt, Bose, McCawley, Burroughs, & Medoff, 2003; Wofford et al., 2004), Canada (Kline et al., 2008) and Australia (Andersson, Allan, & Finucane, 2001). However, today, there are no comprehen- sive international statistics regarding how widespread dissatisfac- tion is with healthcare encounters, care and treatment, as patients’ complaints often are unstructured information expressed in the patient’s own language and on their own terms to the healthcare organization (Montini et al., 2008). According to Wessel et al. (2012), complaints tend to be underreported by those with negative experi- ences of healthcare encounters.

In Sweden, patients’ complaints are most often reported through the Patients’ Advisory Committees (PAC). The PAC is responsible for handling patients’ complaints and they act on behalf of the patients’ or their relatives and strive to solve the problems that have oc- curred together with the involved healthcare professionals (SOSFS, National Board of Health and Welfare, 2005). The PAC also aims to restore the patients’ and relatives’ trust to the healthcare system, viewing complaints as a valuable source of information about pa- tients’ experiences. Complaints can thereby be used positively to identify adverse incidents and to improve quality of care in the fu- ture (Kline et al., 2008; Montini et al., 2008).

Research shows that patients’ reported complaints to the PAC include descriptions of insufficient respect and empathy (Jangland, 2011), experiences of neglect, rudeness, insensitive treatment from healthcare professionals (Skär & Söderberg, 2012; Söderberg, Olsson, & Skär, 2012) and poor healthcare

provider–patient communication (Montini et al., 2008). Negative healthcare encounters cause patients to experience unnecessary anxiety about their health and thus reduce their confidence in the healthcare system. This diminished confidence is affected by healthcare providers’ lack of supportive patient- oriented commu- nication skills as well as by the fact that the patients and health- care professionals have different goals, needs and expectations related to the healthcare encounters (Jangland, Gunningberg, & Carlsson, 2009). The lack of adequate information and commu- nication between patients and healthcare providers has been shown to have a negative impact on patients’ experiences of the quality of care they received (Attree, 2001). When patients do not understand the information being given to them about their health, it might be difficult to ask questions about care and participate in decision- making for treatment or caring (Jangland et al., 2009; Skär & Söderberg, 2012). High- quality communica- tion between patients and healthcare professionals is therefore significant for increasing patients’ satisfaction with healthcare encounters and participation in decision- making (Kourkouta & Papathanasiou, 2014; Petronio, DiCorcia, & Duggan, 2012; Torke et al., 2012).

Patient- reported complaints may be part of the process of im- proving the quality of healthcare encounters (Montini et al., 2008). Moreover, it is not only the issues that gave rise to the patient- reported complaints that are important; the way that the complaints are handled and responded to is likewise important. Veneau and Chariot (2013), stated that answers to complaints are often based on medical information, lack comprehensiveness and show that the healthcare organizations have little intention to investigate the issue further. However, there is a lack of knowledge of how healthcare professionals communicate and respond to patient- reported com- plaints (Andersson, Frank, Willman, Sandman, & Hansebo, 2015). Such knowledge may be used to improve the quality of healthcare encounters and provide insight into how healthcare professionals can create meaningful healthcare encounters. The aim of this study was to explore patient- reported complaints regarding communica- tion and healthcare encounters and how these were responded to by healthcare professionals.

2  | THE STUDY

2.1 | Design

A retrospective and descriptive study design was used to examine patient- reported complaints.

2.2 | Method

This study includes quantitative and qualitative approaches to achieve the study aim. The quantitative approach was chosen to statistically describe the character of the reported complaints to the PAC. The qualitative deductive content analysis was cho- sen to enhance the understanding of the written text of the

226  |     SKÄR and SÖdERBERG

complaints, focusing on the communication between the patients, the involved healthcare professionals and the administrators from the local PAC.

2.3 | Data collection

The study was conducted in collaboration with two adminis- trators from the local PAC in the County Council of northern Sweden, a region with five hospitals and 33 primary healthcare centres. The criteria for inclusion were patient- reported com- plaints concerning encounters and communication reported by adult (over 18 years) patients themselves during January 2010– December 2012. The chosen time period was based on that PAC stored 3 years of complaints at a time. For some complaints, parts of the patients’ records were attached. All identifying patient details have been omitted in the presentation of this study’s re- sults to protect the patients’ anonymity, in accordance with the Helsinki declaration. The patient- reported complaints filed at the PAC were covered by confidentiality. The results of the study are therefore presented only at a group level and individuals cannot be identified.

During the chosen time period, the PAC received 1792 patient- reported complaints concerning issues related to the following areas: i) encounters and communication; ii) medical maltreatment and iii) organizational issues regarding rules/regulations. The admin- istrators at the PAC sorted and classified the complaints in the file archive based on the above- described areas. This sorting was part of the PACs normally classification of complaints and it was performed without a standardized system. To ensure that all complaints that contained dissatisfaction with encounters and communication were included in the analysis all submitted complaints (N = 1792) regard- less of the area where the Patients’ Administrators had sorted them in, were read through. This reading resulted in that all (N = 625) re- ported complaints containing descriptions of dissatisfaction with encounters and communication were selected for the analysis. In 38 of the 625 selected reports, only a short note indicating the date of a phone call to the patient was found and thus these reports were excluded from the analysis. The remaining 587 complaints were in- cluded in the analysis.

2.4 | Statistical analysis

Statistical Package for Social Science (version 22.0; SPSS Inc., Chicago IL, USA) was used for the statistical analyses. Data in the patient- reported complaints regarding gender, the type of organiza- tion, clinical department, reason for the complaint and the type of healthcare professionals who were the focus of the complaint, were extracted to a data template and thereafter included in the SPSS form. Descriptive statistics were used to describe the content and frequencies and a Pearson’s Chi Square test was used to determine the relationships and significant differences between the patient’s gender and the type of units and professions cited in the patient- reported complaints.

2.5 | Deductive content analysis

The written text in the complaints was analysed in parallel with the statistical analysis, using deductive content analysis (Elo & Kyngäs, 2007). Deductive content analysis may be used when the structure of the analysis is based on a specific structured knowledge such as a theory or a model. In this study, the analysis was framed in terms of pre- existing area; encounters and communication, used by the administrators at the PAC when they filed the patient- reported com- plaints into the file archive.

The first step in the analysis was to develop a categorization matrix based on the pre- defined area encounters and communi- cation. Then, all the complaints were reviewed for content and coded for correspondence with one of the field in the area (cf., Elo & Kyngäs, 2007). This means that all text in the patient- reported complaints that describe any form of meetings, appointments and relationships were sorted in the field encounters and that the con- tent in the patient- reported complaints that describe any form of information exchange, communication in form of a written dialog between the patient and the healthcare professionals involved were sorted in the field communication. The content in each field was then compared based on differences and similarities and cat- egories were formulated. The analysis resulted in two categories in each field. The analysis process was non- linear and involved repeated readings of the complaints. To reach a consensus in the analysis, the two authors moved back and forth between content in the complaints and the categories in the field and discussed the content to ensure that the results covered all content in the complaints.

2.6 | Ethics

The authors obtained access to the local PAC file archive after the study received ethical approval from the Regional Ethical Review Board in Sweden (Dnr 06- 050M).

3  | RESULTS

The patient- reported complaints (N = 587) each contained a writ- ten letter from a patient describing the situation that had occurred and indicating dissatisfaction with the healthcare encounter and/ or communication. Each complaint also contained a summary writ- ten by the local PAC administrator as well as a checklist for actions to solve the situation. Furthermore, the reported complaints con- tained an answer from the healthcare professionals involved in the situation and a conclusion regarding how the report was handled and the outcome. Below presents a descriptive summary of the patient- reported complaints characteristics and categories from the deductive content analysis in the two fields; encounters and communication. The qualitative findings are supported by quota- tions from the text in the complaints, written with italic style in the text.

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3.1 | Characteristics of patient- reported complaints

Of the 587 patient- reported complaints, 336 (57%) of these were made by women. The 587 complaints concern all units in the health- care organization and the clinical department that contained most complaints was consultation outpatient visits (N = 195), followed by surgery (N = 171). The complaints described different groups of healthcare professionals who were the focus of the complaint and the most common professions the complaints focus on were phy- sicians (N = 357), followed by healthcare managers (N = 100) and nurses (N = 79). Men’s complaints were more often directed against physicians than were women’s complaints (72% vs. 53%), while women were more likely than men to direct their complaints against healthcare managers (22% vs. 11%). Healthcare manager could be both a ward manager or a person in a higher management level not based in a particular ward or clinic area. Significant differences were found between the professional groups the complaints addressed and the patient’s gender (p = .001) (Table 1).

The result further shows that physicians (N = 221) were most involved in complaints in hospital care followed by healthcare

managers (N = 65) and nurses (N = 51). Significant differences were found between the different professional groups the complaints in- tended to address and the type of organization (p = .001) and clini- cal department (p = .001) the complaint reflect. An overview of the units and the professions that the complaints addressed is provided in Table 2.

A description of the content, frequency and professions involved in the patient- reported complaint is described in Table 3. The re- sults show that 337 of the complaints describe negative attitudes/ behaviour and were distributed as lack of empathy (77%) and non- chalant treatment (23%). Physicians and nurses reportedly showed the greatest lack of empathy (79% vs. 69%), while healthcare manag- ers were most responsible for patients not feeling involved in their care (60%). No significant differences were noted between profes- sionals (p = .419 vs. .552). In the field communication (N = 333), most of the complaints were about the patients’ experiences of not being involved/lack of participation in the care (55%), followed by a lack of information and lack of possibilities for communication (45%). No significant differences were noted between women and men (p = .906 vs. .891).

3.2 | Areas and categories of the deductive content analysis

3.2.1 | The field: Encounters

In the field encounters, two categories were identified; Lack of em- pathy and Non- chalant treatment.

Category: Lack of empathy The complaints often began with a summary of the reasons for the patients’ unhappiness with the meeting. Patients were most dissat- isfied when they were not met in a professional manner. The com- plaints describe that inadequacies in meetings generated feelings of not being met with respect, not being understood and not being welcomed to the healthcare setting. Not being met with respect was described when healthcare professionals did not value the patient as a person. Another reason for reporting a complaint was that health- care professionals could only attend to patients’ most necessary needs when patients found the healthcare environment stressful. The complaints described situations when the patients felt ignored by the healthcare professionals due to insufficient time throughout the caring encounter. One reported complaint described: “there was no time for healthcare professionals to listen to my story so I had to prioritize which needs I should present”. This meant that the patients were dissatisfied with the meeting as focus was only at one of their health instead of all their problems.

The complaints gave also examples of how patients liked to be met by healthcare professionals such as through commitment and a genuine interest by being seen as an important person. In the complaints, the patients further expressed a desire for a resolution to the situation and to prevent it from happening again, either to themselves or to other pa- tients. The patients’ need for justice was another important reason for

TABLE  1 Units and professions that the patient- reported complaint concerns

Women Men Total

p valueN/% N/% N/%

Type of organization

Hospital care 201/60 159/63 360/61

Primary health care

119/35 83/33 202/35

No specific organization

16/5 9/4 5/4

Total 336/100 251/100 587/100 .610

Type of clinical department

Consultation outpatient visits

115/34 80/32 195/33

Medicine 77/23 71/28 148/25

Surgery 110/33 61/24 171/30

Psychiatry 20/6 28/11 48/8

No specific inpatient care

14/4 11/4 25/4

Total 336/100 251/100 587/100 .038

Professionals involved

Physicians 177/53 180/72 357/61

Healthcare managers

73/22 27/11 100/17

Nurses 53/16 26/11 79/13

No specific profession

33/10 18/7 51/9

Total 336/100 251/100 587/100 .001

p ≤ .05 (Pearson’s Chi Square test).

228  |     SKÄR and SÖdERBERG

many of the complaints. One patient perceived in the complaint that: “I had to wait longer than other patients for treatment or care”, another patient describe: “I got less examinations then others”.

Category: Non- chalant treatment The complaints described situations when healthcare profession- als had shown negative attitudes in their behaviour towards the

patients. In some complaints, the patients were referred to as a diagnosis rather than as a person when healthcare professionals were talking among themselves, saying things such as “the bro- ken leg”, “the painful lady” or “the mentally ill”. The patients de- scribe in their complaints that these kinds of negative attitudes and bad behaviour affected their dignity. The patients expressed in the complaints that they would have become healthier sooner

Physician Healthcare managers Nurse No specific profession

p valueN/% N/% N/% N/%

Type of organization

Hospital care 221/62 65/65 51/67 –

Primary health care

136/38 28/28 23/30 –

No specific organization

– 7/7 2/2 –

Total 357/100 100/100 76/100 .001

Type of clinical department

Consultation outpatient visits

132/33 30/49 25/18 1/100

Medicine 115/30 3/4 30/20 –

Surgery 109/28 17/28 45/30 –

Psychiatry 26/6 1/1 22/14 –

No specific inpatient care

14/3 11/18 25/18 –

Total 396/100 62/100 147/100 1/100 .001

p ≤ .05 (Pearson’s Chi Square test).

TABLE  2 Organizations, type of clinical department and involved professionals in the patient- reported complaints

TABLE  3 Analysis fields and categories descriptions of frequencies according patients gender and profession involved in the patient- reported complaints

Analysis fields and categories

Women Men Total

p value

Physician Healthcare managers Nurse

p valueN/% N/% N/% N/% N/% N/%

Field: Encounter

Categories:

Lack of empathy 158/77 101/76 259/77 163/79 41/79 34/69

Non- chalant treatment

47/23 31/24 78/23 44/21 11/21 15/31

Total 205/100 132/100 337/100 .906 207/100 52/100 49/100 .419

Field: Communication

Categories:

Not being involved in care

99/55 82/54 181/55 111/51 40/60 14/56

Answers to the patient’s complaints

82/45 70/46 152/45 105/49 27/40 11/44

Total 181/100 152/100 333/100 .891 216/100 67/100 25/100 .552

p ≤ .05 (Pearson’s Chi Square test).

     |  229SKÄR and SÖdERBERG

if they had been warmly greeted and seen as individuals in their encounters with healthcare professionals. The written text in the complaints indicated that it was unacceptable that the healthcare professionals engaged in this negative behaviour in their meetings with patients.

Dissatisfaction with attitudes and/or negative behaviour in meetings was also described in situations where the patients per- ceived that they were not met in a professional manner. The com- plaints contained examples of caring situations where the patients received insufficient respect, such as a “lack of empathy” and “non- chalant treatment from professionals who ignored their symptoms and illnesses”. Such complaints described how the patients felt lost and ignored in their meetings with healthcare professionals, which in turn led to anxiety. Examples of insufficient respect were also de- scribed in meetings when healthcare professionals talked about the costs of treatment and drugs rather than about the actual treatment of the patients’ symptoms and illnesses. One patient expressed in the written complaints that: “these kinds of attitudes and/or be- haviours, where they were not met in a professional way, negatively affected their health”. As a result, the patients expressed in the com- plaints that their confidence in health care began to diminish.

3.2.2 | The field: Communication

In the field communication, two categories were identified; Not being involved in care and Answers to the patient’s complaints.

Category: Not being involved in care The complaints described that patients experience insufficient infor- mation: “I was not given an opportunity to receive adequate infor- mation or participate in decision- making about my care”. Insufficient information was highlighted because of the language deficits of the provided care. The patients- reported complaints contained exam- ples of situations when the patients suffered due to the methods the healthcare professionals used to inform them. It was for example of situations where: “healthcare professionals use a medical termi- nology that I didn’t understand” or “information was given during stressful circumstances with no time for questions”. The patients ask therefore in their complaints for more information that could explain their circumstances in a way they could understand.

The complaints further indicated that the patients felt that they were not invited to participate in the communication about their treatment and care. One patient expressed in the complaints that: “it is difficult to take part in decision- making about care alternatives when you not be invited”. The patients asked for more communi- cation and their complaints gave examples of situations when the professionals provided information without taking care of the pa- tient’s individual needs. The content in the complaints describe that the patients asked for questions about their needs and personal conditions and an invitation for discussions of alternative treat- ments. One patient’s complaints described: “I know best how I feel so they (the professionals) should ask me”. The patient’s complaints described further that healthcare professional lack interest about

their situation and the patient- reported complaints expressed the patients’ disappointments.

Category: Answers to the patient’s complaints The administrators at the PAC clearly documented the procedure for how the complaints should be handled as well as the resulting outcomes, describing the way they contacted the patients by phone or mail to gather complementary information regarding the situa- tions that had occurred. A checklist described how the administra- tors should further handle the complaints, for example, asking for the patient’s record to get more information about the situation and contacting the involved healthcare professionals. The administra- tors at the PAC always requested an answer and response from the healthcare professionals concerned in the complaints, but responses were received in only 490 cases (83%) of the total 587 complaints. The distribution of answers in re

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