• measures of patient satisfactions;
  • outcomes home health care;
  • patient satisfaction home care;
  • patient satisfaction home health care


  1. Top of page
  2. Abstract
  3. Introduction
  4. Patient satisfaction applications
  5. Differing frameworks for measuring patient satisfaction
  6. Conclusion
  7. Contributions
  8. References

Aims and objectives.  To assess the current use of patient satisfaction measures in home health care and to examine the reliability and validity of current measures of patient satisfaction in home health care.

Background.  Patient satisfaction has been one of the widely used measures in home health care as an indicator of quality of care. A few efforts have been made to develop psychometrically sound patient satisfaction scales for use in home health care.

Design.  A critical review of the literature.

Methods.  Electronic databases were systematically searched to identify the studies or publications that measured and addressed patient satisfaction and its measurement in home health care.

Results.  The review of the literature showed that patient satisfaction measures have been used in the evaluation of care programmes including rehabilitation programmes, discharge and home follow-up programmes, care process and management practices. Also, patient satisfaction measures were used to evaluate new care protocols and treatments.

Conclusions.  Home healthcare agencies need valid and reliable patient satisfaction scales. Frameworks of patient satisfaction are still in their early developmental stage. Only some of the variables related to patient satisfaction are explained by many frameworks.

Relevance to clinical practice.  Home healthcare mangers and researchers need to take in consideration the reliability and validity of measures and tools of patient satisfaction.


  1. Top of page
  2. Abstract
  3. Introduction
  4. Patient satisfaction applications
  5. Differing frameworks for measuring patient satisfaction
  6. Conclusion
  7. Contributions
  8. References

Patient satisfaction is one of the most widely used outcome indicators of quality of health care (Mahon 1996). As a result, patient satisfaction is an active area of research that is increasingly being used to guide health care, because it encompasses patients’ needs. Home healthcare agencies, however, continue to be devoid of empirically valid and reliable patient satisfaction scales. A few studies have evaluated and developed psychometrically sound patient satisfaction scales. This is particularly alarming given the fact that home health care has become the fastest growing sector in health care in the USA. This has lead to numerous patient satisfaction scales being used by differing researchers, which has made it difficult to make broad comparisons and develop interventions to increase patient satisfaction. The current article aims to describe the landscape of patient satisfaction measures in home health care and discuss the available measures of patient satisfaction scales. So, researchers aimed to increase patient satisfaction in home healthcare agencies can make more broad comparisons and develop more comprehensive interventions.

The concept of patient satisfaction was developed in 1957 by Adbellah and Levine (1957) who developed a measure of patient and personal satisfaction with nursing care. In 1980s, hospitals and other healthcare areas started incorporating patient satisfaction as on outcome measure to increase their market share as the healthcare market became increasingly more competitive. In 1990s, patient satisfaction became one of the most important outcomes of care as patients starting more explicitly weighting quality of life with quantity of life. While the emphasis of clinicians has always been to maximise quantity of life, patients (especially at the end of life) are now focusing on quality of life. When the clinicians’ and patient’s goals directly coincide, patient satisfaction will be maximised. As such, patient satisfaction needs to be incorporated in the decision-making concerning the management of a patient and eventually be involved in policy development. The only way to ensure policy development and decision-making is optimised to ensure we can make broad comparisons and provide valid/reliable measurements of patient satisfaction, which can only be achieved by developing and establishing valid/reliable instruments that are advocated by the literature for use.

The increase in patient satisfaction has become a guiding force for health care, and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) required facilities to measure patient satisfaction as an outcome (Long 1999). Similarly, CMS required monitoring of patient satisfaction and other outcomes of care for reimbursement. Currently, patient satisfaction surveys are becoming routine parts of every healthcare organisation. As such, there is a mounting need for tools to reliably and validly measure patient satisfaction. Without a comprehensive investigation of the current tools used in the field, we will be unable to move forward in empirically optimising patient satisfaction. Developing reliable and valid tools will not allow for more broad comparisons, but lead to improvements in patient satisfaction.

Joint Commission on Accreditation of Healthcare Organizations has approved the ORYX accreditation system that integrates outcome and performance measures into the home health accreditation process. ORYX is not an acronym but the name of a gazelle-like animal. ORYX requires all home health agencies to collect outcome data about patient care and submit it to JCAHO on a continuous basis. Home health agencies are expected to examine their delivery of care processes, including patient satisfaction, and make changes to improve the quality and results of care delivered.

All home healthcare agencies in the USA have developed surveys that assess patient satisfaction. Still, a paucity of published literature exists concerning the validity and reliability of patient satisfaction scales in home health agencies. Currently, the US Agency for Health Care and Quality is developing a survey (HCAHPS) that will focus on patient’s perspective on the process of care in home health care including patient satisfaction. The survey has passed many stages of development and is going through the pilot testing phase.

Although patient satisfaction has been one of the many measured care outcomes in home health and other healthcare areas, it is still unclear what the concept of patient satisfaction actually means and how to accurately capture this outcome (Yellen 2003, Wagner & Bear 2009). Wilkin et al. (1992) suggested that this may be explained by the large number of studies that measure patient satisfaction without explaining the concept measured. There is uncertainty about what is the concept of patient satisfaction means (Mahon 1996, Comley & Beard 1998, Yellen 2003, Wagner & Bear 2009). This lack of clarity has led to the development of inadequate measures of patient satisfaction (Lynn et al. 2007).

Patient satisfaction is a multidimensional concept and is inversely related to patient expectations. Patient satisfaction has been described to have elements of subjectivity, expectations and perceptions. Patient satisfaction is a ‘complex mixture of perceived needs, expectations of care, and the experience of care’ (Wilkin et al. 1992) and is a predictor of patients’ behaviours. Behaviours of dissatisfied patients include premature termination of care, non-compliance with prescribed treatment, and terminating membership and trying another plan of care (Donabedian 1988b) and possibly a response to care received. Satisfied customers have been described by Steibert and Krowinski (1990) as loyal and may be trusted to return for more business, care and refer patients, which increases the organisation’s profits and market share, and will most likely improve clinical outcomes.

While Huycke and All (2000) suggested that patients evaluate quality of care based on interpersonal relationships and that patient’s lack the sufficient knowledge and are incapable of judging the quality of care itself, many believe patients can easily identify characteristics of quality of care. Still, the main premise of patient satisfaction that most agree upon is that if the care provided meets the healthcare goal, the patient will be satisfied. Healthcare provider characteristics as well as patient characteristics complicate the assessment of patient satisfaction. Huycke and All (2000) described the following attributes of quality that relate to a patient’s care, including patient satisfaction: ‘(1) Process/structure attributes that include access, availability, cost, continuity, equipment, fairness and justice; (2) Interpersonal attributes such as humanness, responsiveness, caring, respect, communication, beneficence, personality type; (3) Technical attributes such as knowledge, skill, competency, timely, prevention, normal efficiency; and (4) Antecedents of quality attributes such as healthcare knowledge, experience, expectation, physical and emotional needs, values and believes, and perception of needs and care’. Mrayyan (2006) operationally defined patient satisfaction as ‘the degree to which nursing care meets patients expectations in terms of art of care, technical quality, physical environment, availability and continuity of care, and the efficacy/outcomes of care’. What is more clear and well established is that patient satisfaction is one important predictor and indicator of quality of health care (Wagner & Bear 2009).

Nurses provide the largest proportion of healthcare services to patients in all healthcare sectors, particularly in home health care. Adbellah and Levine (1957) were the first to link patient satisfaction to more hours of professional nursing service. Home health care has been targeted by many researchers and in need of many changes that will hopefully lead to decreases in the number of visits. Nurses are facing different forces at the work site that challenge their abilities to provide effective care for their patients. In this time of uncertainty and change, it is essential to monitor patients’ satisfaction. Patient satisfaction is one of the indicators that reflect the situation of quality of care in home health care and is in need of reliable and valid measures to measure patient satisfaction.

Patient satisfaction applications

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patient satisfaction applications
  5. Differing frameworks for measuring patient satisfaction
  6. Conclusion
  7. Contributions
  8. References

A review of the literature shows that patient satisfaction has been used in the evaluation of many healthcare programmes including rehabilitation programmes, discharge and home follow-up programmes, care process, and management practices (Dansky et al. 1994, Rabiner et al. 1995, Gary & Sedhom 1997, Smeenk et al. 1998, Tyson & Turner 2000, Finkelstein et al. 2004, Tsai et al. 2005; Be’land et al. 2006, Jones et al. 2007). Also, it has been used to evaluate new care protocols and treatments (Herrmann et al. 1998, Armstrong et al. 1999, Naylor et al. 1999, Mair & Whitten 2000, Whitten 2000, Zadoroznyj 2006).

The use of patient satisfaction to evaluate healthcare programmes is not an evaluation of care provided only by a home healthcare agency. Care is usually provided by a complementary team of multidisciplinary health service providers, starting typically at either a hospital or a specialty clinic and then the patient is referred to home health care. Therefore, a comprehensive evaluation of the care programme will include different types of services, not all of them strictly related to nursing. In many cases, the new programmes test the use of home health care as a different way to improve the outcomes of care for a specific disease or population of patients (Tyson & Turner 2000, Tsai et al. 2005, Brumley et al. 2007, Cross et al. 2008). Scales used to evaluate patient satisfaction are routinely developed for the specific setting by the investigators conducting the evaluation (Herrmann et al. 1998, Smeenk et al. 1998, Naylor et al. 1999, Tyson & Turner, 1999, Planas et al. 2007). The patient satisfaction assessment tools typically include only 1–4 items and focus on the overall patient satisfaction as well as other specifically selected elements of patient satisfaction. Traditionally, the psychometric properties of the scales used are not provided in many studies. Currently used patient satisfaction scales in programme evaluation and randomised clinical trials do not provide psychometric characteristics of patient satisfaction measures. Although the abstracts of many randomised clinical trials mentioned patient satisfaction, little information has been provided throughout the associated manuscripts (Armstrong et al. 1999, Naylor et al. 1999, Cross et al. 2008). One of the issues in random clinical trials is that the questions developed to assess patient satisfaction are in the specific areas related to the study and the interventions and do not allow for broad comparisons. It is not well established whether the few developed and advocated instruments are accurately measuring patient satisfaction.

Most of programme evaluation and randomised clinical trial studies assessed the overall patient satisfaction. Heineken (1998) found that patients who reported their overall satisfaction in home health care reported routinely major areas of dissatisfaction that they wanted to discuss, including healthcare providers inconsistency (many providers within a week of home care), different approaches of care by different nurses, and some nurses showing no verbal or non-verbal signs of caring.

Many clinical trial studies assess the patient satisfaction after the treatment or the new programme of treatment being evaluated. The goal of these studies is to confirm that the patients are satisfied with the new care process (or the feasibility/acceptability of the new process or intervention). Developments in health care and the new methods of care delivery are ways that would make patients more satisfied with the new treatment than patients receiving alternative methods of existing care or treatment. On the other hand, clinical trial studies in home health care that compared patient satisfaction between experimental and control groups found small differences (Rabiner et al. 1995). It is a challenge to develop responsive and sensitive tools that would convey improved patient satisfaction and outcomes of care in comparative design studies.

Differing frameworks for measuring patient satisfaction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patient satisfaction applications
  5. Differing frameworks for measuring patient satisfaction
  6. Conclusion
  7. Contributions
  8. References

Several approaches have been used to understand what lead patients to become satisfied or dissatisfied with the care they receive. Frameworks have focused on expectations theory (Dansky et al. 1994, Westra et al. 1995) or healthcare service attributes either from the economic theory or the holistic approach (Bear et al. 1999, Crow et al. 2002, McCall et al. 2004, Kroposki & Alexander 2006, Leff et al. 2006). Yellen & Davis 2001 used the systems theory as a framework to assess patient satisfaction.

Obrest (1984) developed the expectation framework that was used to develop the Home Care Client Satisfaction Instrument (HCCSI) (Fig. 1). The framework views satisfaction as ‘the congruency between client expectations of care and perceptions of the care received’ (Westra et al. 1995). The resulting domains in the HCCSI were interpersonal relationship, technical competence, financial aspects, access/convenience, continuity of care, and overall satisfaction. The HCCSI, however, was used only in its published development work and has not been subsequently used by others.


Figure 1.  Framework of client satisfaction. Adopted from ‘Patients’ perceptions of care: Measurement of quality and satisfaction’ by Obrest (1984). Copyright ©1984 American Cancer Society. This material is reproduced with permission of Wiley-Liss, Inc., a subsidiary of John Wiley & Sons, Inc.

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Rabiner et al. (1995), in the study of the relationship between participation in two home- and community-based long-term case management care (known as channelling), tested a model of the determinants of medical care utilisation and satisfaction by using structural equation modelling techniques (LISREL). The model depicts the different direct and indirect relationships among the following variables: basic care, financial control, background factors, prior home health experience, intensity of prior care, homeowner status, and the model of determinants of medical care utilisation and satisfaction that include utilisation of formal in-home care and patient satisfaction. Model diagrams are usually used to clarify the concepts and the relationship between the different variables. However, this model is complicated and does not have foundations in the behavioural or social sciences that would predict or detect satisfaction.

Other researchers have used the qualitative approach to develop patient satisfaction scales. Wilde et al. (1994) developed a patient centred questionnaire using the grounded theory qualitative method. Still, frameworks for measuring patient satisfaction are still underdeveloped and are in their infancy. Huycke and All (2000) explained the many variables that are related to patient satisfaction; however, unfortunately only some of the variables related to patient satisfaction are explained by these frameworks. Further development of more comprehensive theories and frameworks of patient satisfaction is needed and alludes to a very fruitful area of research.

A MEDLINE and CINAHIL search using the phrase ‘patient satisfaction’, ‘client satisfaction’, ‘consumer satisfaction’ in home care resulted in the identification of n = 23 home care patient satisfaction survey scales that were published or referenced in published studies, demonstrating an uncoordinated effort to measure patient satisfaction in home health care, which does not allow for broad comparison. In addition, Table 1 shows each instrument’s Chronbach’s alpha and construct validity statistics, when provided. From Table 1 we can see that 39·1% (n = 9) of the studies failed to report on internal consistency and 52·2% (n = 12) of the studies failed to report on validity. Furthermore, Table 2 includes a list of the dimensions/domains of each instrument, the number of items and the type of scale used.

Table 1. Surveys used to measure patient satisfaction in home health care
Author(s)Name of instrument n (response rate %)Cronbach’salphaConstructvalidity
  1. *Reliability (alpha coefficient) and construct validity established in previous studies.

Armstrong et al. (1999) Modified Patient Satisfaction Questionnaire-III (PSQ-III)181 (39)0·84NA
Bear et al. (1999) Service Coordinator Satisfaction Measure (SCSM)213 (NA)0·86Yes
Brumley et al. (2007) The Reid-Gundlach Satisfaction with Services Instrument166 (83)0·95NA*
Dana and Wambach (2002) KU Med/Maternal Child Home Care Program Patient Satisfaction Questionnaire1840 (24)0·86NA
Dansky et al. (1994) Human Resource Management Practices and Patient Satisfaction Scale (HRPPSS)696 (38)NAYes
Foley et al. (1995) Client Satisfaction Instrument (Modified for HIV Clients)50 (96)NANA
Gary and Sedhom (1997) Gary’s Home Care Satisfaction Scale (GHCSC)NA0·78Yes
Geron et al. (2000) The Home Care Satisfaction Measure (HCSM)228 (61)0·79Yes
Holmqvist et al. (2000) NA81 (94)NANA
Jones et al. (2007) NA21,350 (NA)0·84Yes
Laferriere (1993) Client Satisfaction Survey (CSS) with Home Health Care Nursing (1993)73 (75)0·99Yes
Leggin et al. (2006) The Penn Shoulder Score73 (75)0·93Yes
McCall et al. (2004) NA2588 (78)NANA
Mylod and Kaldenberg (2000) The Press Ganey Home Care Patient Satisfaction Questionnaire22,937 (NA)0·98Yes
Nakatani and Shimanouchi (2004) Client satisfactionNA0·89Yes
Reeder and Chen (1990) Reeder and Chen’s Clients Satisfaction Survey in Home Health Care (1990)35 (NA)0·93NA
Seibert et al. (1999) Patient Satisfaction Care Specific Survey16,772 (55)NANA
Stomper (1998) NA30 (80)NANA
Struyk et al. (2006) Standardised Outcome and Assessment Information Set for Home Health Care – OASIS-B (with modifications)300 (100)NAYes
Tornkvist et al. (2000) Quality of Care from the Patient’s Perspective (QPP)168 (62)NA*NA*
Tsai et al. (2005) Service Satisfaction Instrument80 (100)0·94NA
Westra et al. (1995) The Home Care Client Satisfaction Instrument (HCCSI-R)400 (45)0·93Yes
Wilson et al. (2002) NA83 (91)NAYes
Table 2. Patient satisfaction survey dimensions, number of items and type of scale
Author (s)DimensionsNumber ofitemsResponseformatNumber ofitems in responseformat
Armstrong et al. (1999) General satisfaction18Likert5
Interpersonal manner
Time spent
Accessibility & convenience
Bear et al. (1999) Service delivery19Likert5
Service sufficiency
Brumley et al. (2007) Relevance12ScaleNA
Dana and Wambach (2002) Nurse friendliness13Likert4
Technical skills
Infant care teaching
Individualised care
Dansky et al. (1994) Three overall measuresNALikert5
Scheduling & arrangements
Nursing care
Home health aide services
Discharge arrangements
General measures of satisfaction
Foley et al. (1995) NA34Likert5
Gary and Sedhom (1997) Caring2716 Likert & mixed3
Amount of care/time spent
Geron et al. (2000) Care Management Services Sub-scale:35Likert5
Service choice
Positive interpersonal
Negative interpersonal
Holmqvist et al. (2000) Art of care18Scale5
Technical quality of care
Efficacy/outcome of care
Jones et al. (2007) Carer quality60Multiple choice5
Service quality
Laferriere (1993) Technical quality of care35Scale5
Personal relationships between client & provider
Delivery of services
Leggin et al. (2006) One item Scale4
McCall et al. (2004) Overall satisfaction15NANA
Satisfaction with discharge experience
Satisfaction with agency staff
Mylod and Kaldenberg (2000) Arranging your home health care35Likert5
Dealing with the home care office
Home health aides
Medical equipment
Overall ratings
Nakatani and Shimanouchi (2004) Client focus46Scale4
Continuity of care
Coordination of services
Integration of services
Effectiveness and efficiency
Reeder and Chen (1990) Communication among patient, family, provider35Likert5
Competence of technical care
Provider, patient, and family relationship
Seibert et al. (1999) Care process27Forced choiceNA
Patient involvement education
Orientation to homecare
Perceived medical outcome
Stomper (1998) NA5Likert5
Struyk et al. (2006) Services delivered35Likert3
Services quality
Specific service satisfaction
General service satisfaction
Tornkvist et al. (2000) Medical–technical competence of the care giver34Likert4
The physical–technical conditions of the care organisation
The degree of identity orientation in the attitudes & actions of the care givers
The socio-cultural atmosphere of the care organisation
Tsai et al. (2005) Convenience11ScaleNA
Time consumed
Nurses’ professional
Service content
Providers’ attitudes
Caregiver’s burden
Westra et al. (1995) Uni-dimensional scale12Likert5
Wilson et al. (2002) NA14Scale4

Many scales are scored on a three-point Likert scale ranging between unsatisfied (1) and satisfied (3) patients. For more robust scale sensitivity, there is a need to increase the number of choices on the Likert scales used in the instruments. As mentioned earlier, there is an inherent need for scale sensitivity when using these instruments in RCTs. Patient improvements are usually obtained in small incremental increases. Using tools’ results that stratify responses into either satisfied or unsatisfied patients leads to such small variances that unfeasible sample sizes are required to adequately power the associated studies. The following will examine three different patient satisfaction scales.

The Human Resource Management Practices and Patient Satisfaction Scale (HRPPSS) defined patient satisfaction as ‘a construct that incorporates a personal evaluation of healthcare services and providers’. The items of the HRPPSS scale are published and listed in a shortened way. It is not clear whether the language used in the shortened list is the same language used in the questionnaire. The published study did not provide measures of validity and reliability of the new developed HRPPSS scale.

Seibert et al. (1999) develop three questionnaires to measure patient satisfaction across the ambulatory continuum of care. The three points of care were outpatient testing and therapy services (TT), outpatient surgery (OS), and home health care (HH). For this study, we are interested in the HH patient satisfaction scale. The Seibert home health scale developed as part of assessing patient satisfaction across three points of care had similar characteristics as other home health patient satisfaction measures. The items contained words that have a reading level higher than the six grade and included words such as ‘perceived’, ‘dependability’, and ‘orientation’. The sentences are not as simple such as ‘staff arrives in timely manner’. A simple statement of this sentence would be ‘nurse arrives on time’. Words such as ‘seems to’ and ‘questions/services’ are not usually clear to respondents. Respondents sometime believe I am asking for questions but not for services. The published works on scale development did not include a definition or a framework for satisfaction. There is no sum score for the scale, which leads to the use of individual item scores in validity and reliability assessment testing. Factor analysis served as a support to construct validity.

The HCCSI was developed based on a review of the literature, findings of quality improvement in home health, nurse expert opinions, and three pilot studies (Westra et al. 1995). Also, the HCCSI is a modification of the Outpatient Satisfaction Questionnaire (OSQ-37). The scale takes 10 minutes to complete. The final scale was called HCCSI-R with 12 items rated on a five-point scale (1 = very satisfied and 5 = very dissatisfied) and three global satisfaction items rated on a 10-point Likert scale. The survey took 10 minutes to be completed. The final survey was uni-dimensional. The items used words such as ‘courteous’, ‘involvement’, and ‘consistently’. Compound long sentences were used such as ‘Having the same people consistently so they understood how you like care done’. The instructions at the top of the questionnaire stated that, ‘if an item doesn’t apply, skip it and move to the next item’. The instruction may be associated with the large number of missing data. Clients could have been asked to rate the importance of an item as well as their satisfaction. One of the psychometric study criteria was that only patients who have received care for at least two months could participate in the study. According to the NHHCS (1996), most of the patients received short visits and tended to have a very short length of stay. In addition, the patients’ satisfaction was evaluated during the care process.


  1. Top of page
  2. Abstract
  3. Introduction
  4. Patient satisfaction applications
  5. Differing frameworks for measuring patient satisfaction
  6. Conclusion
  7. Contributions
  8. References

There are many patient satisfaction assessment measures. Nearly all scales did not define patient satisfaction and a few used frameworks for patient satisfaction in home health care. To develop patient satisfaction measures, the construct and the theoretical frameworks of patient satisfaction in home health need to be included in published studies. The current situation of patient satisfaction measures limits the availability of psychometric information and characteristics that could help advance the measurement of patient satisfaction in home health care. Patient satisfaction is a multidimensional concept that requires psychometrically appropriate scales to be measured, including reliability and validity assessment.


  1. Top of page
  2. Abstract
  3. Introduction
  4. Patient satisfaction applications
  5. Differing frameworks for measuring patient satisfaction
  6. Conclusion
  7. Contributions
  8. References

Review of the literature: SA, YA; critique and tables: JM and manuscript preparation: SA, JM, YA.


  1. Top of page
  2. Abstract
  3. Introduction
  4. Patient satisfaction applications
  5. Differing frameworks for measuring patient satisfaction
  6. Conclusion
  7. Contributions
  8. References
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The Journal of Clinical Nursing (JCN) is an international, peer reviewed journal that aims to promote a high standard of clinically related scholarship which supports the practice and discipline of nursing.

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