chapter 1: overview of the study · phenomenological analysis (ipa) approach, guided by the...
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RAISING THE VOICE OF
DISSATISFACTION: A QUALITATIVE
STUDY OF THE QUEENSLAND ACUTE
HEALTH CARE CONSUMER AND THE
EXPERIENCE OF COMPLAINING
Matylda Iwanna Howard
RPN, RGN, BNg, MBA (Quality Mgt), MRCNA
Professor Marylou Fleming (Principal Supervisor)
Associate Professor Elizabeth Parker (Associate Supervisor)
Submitted in fulfilment of the requirements for the degree of
Doctor of Health Science
Institute of Health and Biomedical Technology
Faculty of Health
School of Public Health
Queensland University of Technology
2011
ii
RESEARCH ACTIVITIES
Conferences
Howard, M (2009). Understanding the disparity between the actual number of
patients that complain and those that want to complain but don‘t. Poster
Presentation. Risk and Patient Safety Conference. 24-25 November.
London, United Kingdom. http://www.healthcare-
events.co.uk/conf/booking.php?action=home&id=327
Howard, M (2009). Effective communication is the key to improving complaints
handling from dissatisfied taciturn patients. Oral Presentation.
International Conference on Communication in Healthcare (ICCH). 4-7
October, 2009. Florida, USA
http://www.aachonline.org/programs/internationalconference/
Howard, M (2009). A Phenomenological exploration of the experience of
complaining by Queensland patients. Oral Presentation. International
Human Services Research Conference 17-20th
June. Molde, Norway.
http://www.himolde.no/index.cfm?pageID=2416
Howard, M (2008). The management of complaints from the health care
consumer‘s perspective. Oral Presentation. National Forum on Safety
and Quality in Health Care. 29-31 October, Adelaide, South Australia.
http://www.achs.org.au/FriPresentations/#3551
Howard, M (2008). The management of complaints from the patient‘s
perspective. Oral Presentation. Australian Council of Health Services
Executives (ACHSE), Queensland State Conference. 29-30 May,
Surfers Paradise, Queensland. http://www.achse.org.au/frameset.html
Television
Howard, M (2007). Health care patient complaints study. Television Interview.
Channel Seven News. 5 November, Bundaberg, Queensland
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KEYWORDS
Australia
Cognitive Appraisal
Consumer Satisfaction
Complaints
Dissatisfaction
Emotions
Health Services
Heidegger
Hermeneutic
Leximancer™
Patients
Phenomenology
Queensland
Satisfaction
iv
ABSTRACT
Research into complaints handling in the health care system has
predominately focused on examining the processes that underpin the
organisational systems. An understanding of the cognitive decisions made by
patients that influence whether they are satisfied or dissatisfied with the care
they are receiving has had limited attention thus far. This study explored the
lived experiences of Queensland acute care patients who complained about some
aspect of their inpatient stay.
A purposive sample of sixteen participants was recruited and interviewed
about their experience of making a complaint. The qualitative data gathered
through the interview process was subjected to an Interpretative
Phenomenological Analysis (IPA) approach, guided by the philosophical
influences of Heidegger (1889-1976). As part of the interpretive endeavour of
this study, Lazarus’ cognitive emotive model with situational challenge was
drawn on to provide a contextual understanding of the emotions experienced by
the study participants.
Analysis of the research data, aided by Leximancer™ software, revealed
a series of relational themes that supported the interpretative data analysis
process undertaken. The superordinate thematic statements that emerged from
the narratives via the hermeneutic process were ineffective communication,
standards of care were not consistent, being treated with disrespect, information
on how to complain was not clear, and perceptions of negligence.
This study‘s goal was to provide health services with information about
complaints handling that can help them develop service improvements. The
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study patients articulated the need for health care system reform; they want to be
listened to, to be acknowledged, to be believed, for people to take ownership if
they had made a mistake, for mistakes not to occur again, and to receive an
apology.
For these initiatives to be fully realised, the paradigm shift must go
beyond regurgitating complaints data metrics in percentages per patient contact,
towards a concerted effort to evaluate what the qualitative complaints data is
really saying. An opportunity to identify a more positive and proactive approach
in encouraging our patients to complain when they are dissatisfied has the
potential to influence improvements.
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TABLE OF CONTENTS
Research Activities ................................................................................................................................. ii
Keywords .............................................................................................................................................. iii
Abstract ..................................................................................................................................................iv
Table of Contents ...................................................................................................................................vi
List of Figures ......................................................................................................................................... x
List of Tables .........................................................................................................................................xi
List of Abbreviations ............................................................................................................................ xii
Statement of Original Authorship ....................................................................................................... xiii
Copyright Statement ............................................................................................................................ xiii
Acknowledgements .............................................................................................................................. xiv
CHAPTER 1: OVERVIEW OF THE STUDY ......................................................................... 1
1. Background .................................................................................................................................. 1
1.1. The Changing Complaints Culture in Queensland, Australia ...................................................... 2 1.1.1. Other Influences .................................................................................................. 3
1.2. Aim of the Study .......................................................................................................................... 6 1.2.1. Personal Reflections ............................................................................................ 7
1.3. Significance of the Study ............................................................................................................. 8
1.4. Structure of the Thesis ................................................................................................................. 9 1.4.1. Chapter 1: Overview ......................................................................................... 10 1.4.2. Chapter 2: Literature Review ............................................................................ 10 1.4.3. Chapter 3: Methodology, Design and Methods ................................................. 11 1.4.4. Chapter 4: Findings ........................................................................................... 12 1.4.5. Chapter 5: Examination of Key Themes ........................................................... 13 1.4.6. Chapter 6: Conclusion and Recommendations .................................................. 13
CHAPTER 2: LITERATURE REVIEW ................................................................................ 14
2. Introduction ................................................................................................................................ 14
2.1. Search Strategies ........................................................................................................................ 15
2.2. Defining the Terms .................................................................................................................... 15 2.2.1. Complaints Management ................................................................................... 15 2.2.2. Types of Complaints ......................................................................................... 16
2.3. Impact of Complaints Handling ................................................................................................. 23
2.4. Complaints Research ................................................................................................................. 24 2.4.1. Australian Health Care Consumer Satisfaction Studies 1989-2009 .................. 26 2.4.2. Summary of Table 3 .......................................................................................... 36
2.5. Complaints Handling: A Twenty Year Perspective 1989-2009 ................................................. 38 2.5.1. Confirming Satisfaction with Service Areas ..................................................... 38 2.5.2. Evaluation of Quality/Change Management Initiatives..................................... 46 2.5.3. Identification of Organisational Impacts ........................................................... 48 2.5.4. Examination of the Experience of Complainants‘ and Influences of
Satisfaction ..................................................................................................................... 50
2.6. Concept Map of Complaints Resources ..................................................................................... 53
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2.7. Summary of Australian Health Reforms .................................................................................... 54 2.7.1. Australian Charter of Healthcare Rights ........................................................... 57 2.7.2. National Health and Hospitals Network Agreement (NHHN) .......................... 58
2.8. Summary .................................................................................................................................... 59
CHAPTER 3: METHODOLOGY, DESIGN AND METHODS ........................................... 61
3. Introduction ................................................................................................................................ 61
3.1. Methodology .............................................................................................................................. 62 3.1.1. Study Design ..................................................................................................... 62 3.1.2. Domains of Phenomenological Inquiry ............................................................. 65 3.1.3. Orientations in Phenomenology ........................................................................ 68 3.1.4. Writing .............................................................................................................. 68 3.1.5. Methodological Impulses .................................................................................. 70 3.1.6. Sources of Meanings ......................................................................................... 71 3.1.7. Contextual Framework ...................................................................................... 71 3.1.7.1. Q1: The Emotion of Anger ............................................................................. 74 3.1.7.2. Q2: Consumer/Customer Right to Complain ................................................. 74 3.1.7.3. Q3: Motivation to Complain .......................................................................... 75 3.1.7.4. Q4: Influences on Future Hospital Admissions .............................................. 76
3.2. Methods and Procedures ............................................................................................................ 76 3.2.1. In-depth Interviews............................................................................................ 76 3.2.2. Model of Emotions and Core Relational Themes .............................................. 79
3.3. Sample Information and Instruments ......................................................................................... 80 3.3.1. Recruitment Strategy ......................................................................................... 80
3.4. Step 1—Preparation ................................................................................................................... 83 3.4.1. Sampling Criteria .............................................................................................. 83 3.4.2. Alternative Target Group Identification ............................................................ 83
3.5. Step 2—Making Contact ............................................................................................................ 86 3.5.1. Ethical Considerations ....................................................................................... 86 3.5.2. Establishing Confirmation ................................................................................. 86 3.5.3. Interview Guide ................................................................................................. 89 3.5.4. Thesis Process and Interview Timeline ............................................................. 90
3.6. Step 3—Providing Follow-up .................................................................................................... 91
3.7. Data Analysis ............................................................................................................................. 91 3.7.1. Introduction to the Analysis .............................................................................. 91 3.7.2. Undertaking the Analysis of the Data................................................................ 93 3.7.2.1. Transcription .................................................................................................. 94 3.7.2.2. First Level Reading ........................................................................................ 94 3.7.2.3. Structural Analysis ......................................................................................... 94 3.7.2.4. Relational Themes and Emergence of Superordinate Themes ....................... 95
3.8. Establishing Rigour .................................................................................................................... 95
3.9. Summary .................................................................................................................................... 97
CHAPTER 4: FINDINGS—ASSIGNING MEANINGS TO THE WORDS ....................... 98
4. Introduction ................................................................................................................................ 98
4.1. Everyday World ......................................................................................................................... 99 4.1.1. Description of the Participants .......................................................................... 99
4.2. Setting the Scene ...................................................................................................................... 102 4.2.1. Presentation of Findings .................................................................................. 102
4.3. Seeing Through the Eyes of Others ......................................................................................... 102
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4.3.1. Emotionally Significant Event ........................................................................ 102 4.3.2. Where Has All the Good Service Gone? Nick & Emma ................................. 104 4.3.3. For Our Loved Ones: William, Audrey, Michael, & Isabella ......................... 107 4.3.4. It's Not Just About Me: Andrea, Charlotte, & Zoey ....................................... 115 4.3.5. I Deserve Proper Care: Mia, Grace, Madeline, Katherine, Jonathon, Ava,
& Samuel ...................................................................................................................... 121
4.4. Cognitive and Physiological Influences ................................................................................... 124 4.4.1. Primary Appraisal............................................................................................ 124
4.5. Flight or Fight .......................................................................................................................... 126 4.5.1. Secondary Appraisal........................................................................................ 126
4.6. Coping Strategies and the Experience of Emotion ................................................................... 129 4.6.1. Appraisal Outcome .......................................................................................... 129 4.6.2. Examination of Themes with Leximancer Software ....................................... 130
4.7. Summary—Participant Complaints, Emerging Sub-Themes, & Superordinate Theme
Statements ........................................................................................................................................... 134
CHAPTER 5: EXAMINATION OF KEY THEMES AND DISCUSSION ....................... 139
5. Introduction .............................................................................................................................. 139
5.1. Sources of Meanings ................................................................................................................ 140 5.1.1. Theme 1: Ineffective Communication ............................................................. 140 5.1.2. Theme 2: Treated with Disrespect ................................................................... 146 5.1.3. Theme 3: Standards of Care Are Not Consistent ............................................. 149 5.1.4. Theme 4: How to Make a Complaint is Not Clearly Evident .......................... 152 5.1.5. Theme 5: Perception of Negligence ................................................................ 155 5.1.6. Emotions that Precede a Complaint ................................................................ 156 5.1.7. Equity in Complaining .................................................................................... 157 5.1.8. Motivation to Complain .................................................................................. 158 5.1.9. Future Admissions ........................................................................................... 159 5.1.10. Thematic Correlations and Patient-Centred Care .......................................... 160
CHAPTER 6: CONCLUSION, LIMITATIONS, AND RECOMMENDATIONS ........... 163
6. Introduction .............................................................................................................................. 163
6.1. Conclusion ............................................................................................................................... 164
6.2. Learning from Patients To Inform Service Improvement ........................................................ 165 6.2.1. Planning ........................................................................................................... 167 6.2.2. Doing ............................................................................................................... 167 6.2.3. Theme: Ineffective Communication ................................................................ 168 6.2.3.1. Issue 1: To be Listened to and Supported ..................................................... 168 6.2.4. Theme: Treated with Disrespect ...................................................................... 169 6.2.4.1. Issue 2: To be Believed and Acknowledged .................................................. 170 6.2.5. Theme: How to Make a Complaint is not Clear .............................................. 171 6.2.5.1. Issue 3: To be Informed ................................................................................ 172 6.2.6. Themes: Treatment Issues and Perceptions of Negligence ............................. 173 6.2.6.1. Issue 4: Taking Ownership if a Mistake Has Been Made ............................. 174 6.2.6.2. Issue 5: Mistakes Not to Occur Again .......................................................... 175 6.2.6.3. Issue 6: To Receive an Apology .................................................................... 176 6.2.7. Checking.......................................................................................................... 177
6.3. Limitations ............................................................................................................................... 178
6.4 Recommendations –Through The Lens of Change .................................................................. 180 6.4.1 Acting ................................................................................................................... 180 6.4.1.1 Recommendation 1 ........................................................................................ 182 6.4.1.1.1 Improving Communication ......................................................................... 182
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6.4.1.1.2 Relationship Building ................................................................................. 184 6.4.1.2 Recommendation 2 ........................................................................................ 185 6.4.1.2.1 Learning From Our Mistakes—Patient Safety ........................................... 185 6.4.1.3 Recommendation 3 ........................................................................................ 187 6.4.1.3.1 Confirming Information, Who is Doing What? .......................................... 187
6.5 Future Research ....................................................................................................................... 188 6.5.1 Proposed Study 1—Broader Sample .................................................................... 188 6.5.2 Proposed Study 2—Leadership, Communication Cultures and Patient-
Centred Care ................................................................................................................. 191
6.6 Concluding Summary .............................................................................................................. 191
REFERENCE LIST ................................................................................................................. 194
APPENDICES .......................................................................................................................... 220 Appendix A: Recruitment Flow Chart .......................................................................... 220 Appendix B: Human Ethics Approval Certificate ........................................................ 221 Appendix C: Recruitment Advertisement ..................................................................... 223 Appendix D: Introduction Letter/Email ........................................................................ 224 Appendix E: Participant Information and Consent Form ............................................. 225 Appendix F: Emotions Checklist .................................................................................. 228 Appendix G: CSP Extract of Interview with Coding & Thematic Considerations ....... 229 Appendix H: CSP–Relational Statements and Superordinate Themes ......................... 232 Appendix I: Peer Grouping Criteria .............................................................................. 235 Appendix J: Leximancer Concept Maps ....................................................................... 236 Appendix K: Group and Participants Findings of Emotions Data ................................ 238 Appendix L: All CSP—Combined Percentage of Emotions—Pie Chart...................... 239 Appendix M: Theme 1: Ineffective Communication (extract examples) ...................... 240 Appendix N: Theme 2: Treated with Disrespect (extract examples) ............................ 243 Appendix O: Theme 3: Standards of Care are Not Consistent (extract examples) ....... 245 Appendix P: Theme 4: Information is Not Clear (extract examples) ........................... 249 Appendix Q: Theme 5: Perceptions of Negligence (extract examples) ........................ 253 Appendix R: Poster—London, UK. .............................................................................. 255 Appendix S: Oral Presentation—Miami, USA ............................................................. 256 Appendix T: Oral Presentation—Molde, Norway ........................................................ 257 Appendix U: Oral Presentation—Adelaide, South Australia ........................................ 258 Appendix V: Oral Presentation—Surfers Paradise, QLD ............................................. 259 Appendix W: Confirmation Seminar Notification ........................................................ 260 Appendix X: Final Seminar Notification ...................................................................... 261 Appendix Y: Acceptances for oral/poster presentation but unable to attend ................ 262
x
LIST OF FIGURES
Figure 1: TQM Framework: Plan, Do, Check, Act Cycle .................................................................... 47
Figure 2: Concept Map for Complaints Research in Queensland, Australia ........................................ 54
Figure 3: Domains of Phenomenological Inquiry ................................................................................ 67
Figure 4: Simplified Cognitive Appraisal Theory ............................................................................... 72
Figure 5: Cognitive Appraisal Process Identification of the Situation/Event .................................... 103
Figure 6: Cognitive Appraisal—Primary Appraisal Process ......................................................... 124
Figure 7: Cognitive Appraisal—Secondary Appraisal Process ...................................................... 127
Figure 8: Cognitive Appraisal—Appraisal Outcome ...................................................................... 130
Figure 9: Leximancer Concept Map for Michael and Isabella .......................................................... 131
Figure 10: Thematic Correlations and Patient-Centred Care ............................................................ 162
Figure 11: Thematic Concept Map—Isabella and Michael................................................................ 236
Figure 12: Thematic Concept Map—Andrea ..................................................................................... 236
Figure 13: Thematic Concept Map—Charlotte .................................................................................. 237
Figure 14: Thematic Concept Map—Audrey ..................................................................................... 237
Figure 15: All CSP—Combined Percentage of Emotions—Pie Chart ............................................... 239
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LIST OF TABLES
Table 1: Thesis Structure ........................................................................................................................ 9
Table 2: Australian State and Territory Jurisdictions Managing Complaints about Health Care ......... 18
Table 3: Australian Health Care Consumer Satisfaction Studies 1989-2009 ....................................... 26
Table 4: Literature Review—Where studies were conducted .............................................................. 36
Table 5: Emotions Table ...................................................................................................................... 79
Table 6: Sampling and Recruitment Strategy Checklist ....................................................................... 81
Table 7: Participant Information Sheet ................................................................................................. 87
Table 8: Complaints Study—Interview Guide ..................................................................................... 89
Table 9: Thesis Process and Interview Timeline .................................................................................. 90
Table 10: Participant Identifier and Pseudonym .................................................................................. 93
Table 11: Complaints Study Participants—Gender .............................................................................. 99
Table 12: Complaints Study Participants—Patient/Advocate .............................................................. 99
Table 13: Complaints Study Participants—Age ................................................................................. 100
Table 14: Complaints Study Participants—Country of Birth ............................................................. 100
Table 15: Complaints Study Participants—Type of Hospital ............................................................ 101
Table 16: Complaints Study Participants—Other Agencies involved ................................................ 101
Table 17: Summary of Participants and Findings .............................................................................. 134
Table 18: Google News Alerts ........................................................................................................... 180
Table 19: Complaint Study Participants (CSP) Group Findings—n and % Emotions Identified in
Narrative ..................................................................................................................................... 238
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LIST OF ABBREVIATIONS
The following acronyms and abbreviations appear throughout this thesis.
ACHS Australian Council on Healthcare Standards
ACSQHC Australian Commission on Safety and Quality in Healthcare
AHMAC Australian Health Ministers‘ Advisory Council
CALD Culturally and Linguistically Diverse
CSP Complaint Study Participants
EQuIP Evaluation and Quality Improvement Program
HCIP Health Complaint Information Program
HQCC Health Quality and Complaints Commission
IPA Interpretative Phenomenological Analysis
IPIR Interim Compensation and Professional Indemnity in Health Care Report
NHHN National Health and Hospitals Network Agreement
OD Open Disclosure
PDCA Plan—Do—Check—Act
PIR Compensation and Professional Indemnity in Health Care, Final Report
QAHCS The Quality in Australian Health Care Study
QUT Queensland University of Technology (Australia)
SOCAP Society of Consumer Affairs Professionals in Business Australia
The Collaboration Consumer Focus Collaboration group
TQM Total Quality Management
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STATEMENT OF ORIGINAL AUTHORSHIP
The work contained in this thesis has not been previously submitted to meet
requirements for an award at this or any other higher education institution. To the
best of my knowledge and belief, the thesis contains no material previously
published or written by another person except where due reference is made.
Signature: _________________________
Date: 22nd February 2011
COPYRIGHT STATEMENT
© 2011 Matylda I. Howard
This thesis is copyright. Except for the quotation of short passages for the
purposes of review, no part of this thesis may be reproduced, stored in a retrieval
system, or transmitted, in any form or by any means, electronic, mechanical,
photocopying, recording or otherwise, without prior permission of the author.
All rights reserved.
xiv
ACKNOWLEDGEMENTS
I would like to acknowledge and thank my Principal Supervisor, Professor
Marylou Fleming, who has been with me from the beginning. Thank you for your
guidance, support, and expertise throughout all aspects of this study. Over the
course of this study program I have had three Associate Supervisors, and I would
like to thank each and every one of them. Of particular note is Associate Professor
Elizabeth Parker, whose constant positive reinforcement and belief in me has been
very important to me throughout this entire time.
A deep sense of gratitude is extended to the participants of this study who
shared their experiences with me. At times many of their reflections were difficult
for them to recount, but they all had a sense of wanting to help to improve the
―system‖ for other patients. A standout reflection by one of the participants that
spoke volumes to me was expressed by Isabella ...I never had a voice. I have
found some voice but it’s still not loud enough...This small expression captured the
essence of the study.
I would like to acknowledge and thank my parents who have always
encouraged the pursuit of knowledge. At times in my youth I may not have always
heard that message but I have certainly become an advocate of that philosophy now.
Finally, I would like to dedicate the completion of this thesis to my husband
Paul. He has never faltered in his support and positive reinforcement of my
capacity to undertake this thesis. Those days when I doubted myself were quickly
swept away with his capacity to envelop me with love and confidence that I could
indeed do this.
Chapter 1: Overview of the Study
1
Chapter 1: Overview of the Study
1. BACKGROUND
There is no disputing the relevance that an effective complaints handling
system can have to revealing either actual or potential incidents of concern
(Brouwer, 2007; Hsieh, Thomas, & Rotem, 2005; Nisselle, 2004; Romios,
Newby, Wohlers, Spink, Gleeson, & Goldstein, 2003; Wilson & Fulton, 2000).
From the literature reviewed, the clear message is that there is a changing
landscape in Australia of complaints culture, and that complaint handling should
not be managed by a specific department or an individual but that the
responsibility must be assumed by the organisation as a whole. This study
examines the narratives of sixteen participants who experienced the complaint
process in Queensland acute care hospitals.
―When complaints are freely heard, deeply considered and
speedily reformed, then is the utmost bound of civil liberty
attained that wise men look for‖ John Milton, Areopagitica, 1644.
Chapter 1: Overview of the Study
2
1.1. THE CHANGING COMPLAINTS CULTURE IN QUEENSLAND,
AUSTRALIA
In 2005 in Queensland, Australia, the media reported claims of a surgeon
dubbed ―Dr Death‖1 being investigated over the deaths of eighty-seven patients
in a country public hospital (Van Der Weyden, 2005). This report led to many
people asking questions about the efficacy of the existing complaints processes
in the Queensland health system and how patients engage with the process if,
and when, they are dissatisfied (Queensland Health Systems Review, Final
Report, 2005). A commission of inquiry was established to investigate these
serious allegations. Public forums and many submissions received by the Royal
Commission raised consistent concerns about the inability of health services in
Queensland to adequately deal with complaints, whether from patients or staff
(Queensland Health Systems Review, Final Report, 2005).
The Commission reported that there was inconsistency of approach
across the state for dealing with the various complaint categories. It reported that
the public did not have a satisfactory complaints system upon which to rely, nor
were there sufficient patient support mechanisms in place. This observation
could be substantiated on many levels, but perhaps the most relevant came from
the ―Patel case‖. Evidence was able to be presented that revealed that serious
complaints were raised within the first eight weeks of that surgeon‘s
appointment at the hospital, and yet serious and life-threatening outcomes to
1 Referred to hereafter in this thesis as the 'Patel case'
Chapter 1: Overview of the Study
3
patients continued to be ignored for the next two years. ―One must ask then how
the system failed so badly‖ (Queensland Public Hospitals Commission of
Inquiry Report, p, 171). Overall it was reported by the Commissioner that the
handling of consumer complaints by health services in Queensland had ―not
routinely been accessible, transparent, and accountable or used to improve the
quality of a health service‖ (Health Community Council, Handbook, 2008, p.
42). On 29 June, 2010, in the Queensland Supreme Court, Dr Patel was found
guilty of three counts of manslaughter and one count of grievous bodily harm.
1.1.1. Other Influences
Over the last twenty years a series of significant events have undergone
public scrutiny, highlighting the inadequacies in complaints handling by health
services in Australia. A major study commissioned by the Commonwealth
Government in 1991was the Review of Professional Indemnity Arrangements for
Health Care Professionals; this study examined the ―adequacy of compensation
and funding arrangements for health care misadventures in Australia‖ (Final
Report: Taskforce on Quality in Australian Health Care, 1996, p. A10). As a
result of this study, many other issues and recommendations emerged. The final
report was released approximately five years after its commencement in 1996.
Of particular interest is that many of the recommendations were about
―better use of alternative dispute resolution mechanisms, through their various
health care complaints mechanisms, as well as ways of improving
communication between health professionals and health care consumers‖
Chapter 1: Overview of the Study
4
(Compensation and Professional Indemnity in Health Care, Final Report (PIR),
1996, p. 14). Overall the Taskforce report investigation reported one hundred
and sixty-eight recommendations for action. Several themes emanated from the
review and were used to drive the recommendations into action. An important
focus of interest to this research is the recommendation for ―establishing
effective and accessible complaints and disciplinary processes‖ (PIR, 1996, p.
43). The review led to The Quality in Australian Health Care Study (QAHCS)
that explored and clarified issues presented in the 1993 Interim Compensation
and Professional Indemnity in Health Care Report (IPIR) including focussing on
complaints processes (PIR, 1996).
Many of the findings from the 1995 QAHCS report led to a Taskforce
being established by the Commonwealth Government to review the actual
number of preventable adverse events that were being identified. The Taskforce
reported their findings within six months directly to the Commonwealth Minister
for Human Services and Health (PIR, 1996). Essentially, the Taskforce proposed
strategies to respond to the findings of the QAHCS. In 1996 adverse events were
reported as occurring in 16.6% of admissions of Australian patients to health
care facilities (Final Report: Taskforce on Quality in Australian Health Care,
1996, p. A72).
Since that report there have been a variety of studies and reports
analysing the findings reported in the QAHCS (Milgate, 2003; Newell, Jones, &
Hatlie, 2010; Scobie, Thomson, McNeil, & Phillips, 2006; Wilson & Van Der
Chapter 1: Overview of the Study
5
Weyden, 2005). The overall message from the studies and report is that there
must be recognition of the complexity and changing nature of the Australian
health care system. Results must be closely scrutinised and validated before we
can inculcate a culture of quality and safety in the health care system (Healy &
Braithwaite, 2006).
The voice of patients and their expectations of service delivery have
certainly been well promoted by many consumer advocacy services over the
years. For example, the Consumer Focus Collaboration group (The
Collaboration) was a national body which operated in Australia for four years
during the late 1990‘s. The Collaboration was established in 1997 following
recommendations made by the Taskforce on Quality in Australian Health Care,
which recognised and highlighted the important link between consumer
participation and improving health service quality (Johnson & Silburn, 2000).
This group focused on addressing the needs of health consumers who wanted to
be more involved in the ―planning, delivery and evaluation of health services, in
health policy, and in the broader cultural values of the health and medical fields‖
(Gregory, 2006, p. 37). This national body remained functional until the focus
towards accreditation of services became more prominent and with the
establishment of other peak bodies, such as The Australian Council for Safety
and Quality in Health Care and The National Institute for Clinical Studies.
In 2002, approximately fifty prominent consumer stakeholders who were
involved in promoting participation in health, convened to evaluate what ‗The
Chapter 1: Overview of the Study
6
Collaboration‘ had achieved over the years. At this conference there was a
strong focus on recommending a national approach to complaints handling to
reflect a ‗best practice‘ framework. Six years later, in November 2008, the
Australian Health Ministers' Advisory Council (AHMAC) proposed national
arrangements for handling complaints, conduct, health and performance
arrangements. During the consultative process AHMAC received more than 600
submissions in response to the proposed arrangements. While there was strong
evidence to support the value of a national approach to complaints handling, the
framework overall was not fully supported. So, over the last 20 years a robust
discussion about the value of a national complaints handling system has
occurred in the Australian health industry, but as of July 1, 2010 only a partial
national approach to complaints handling has been implemented.
1.2. AIM OF THE STUDY
This study aims to explore the experiences of individuals who have
complained about some aspect of their in-patient care in an acute care
Queensland hospital. It examines the experience from patients who have
complained and provides insights into how complaints handling is actually
perceived by patients. The primary research questions that will guide this study
are: What can be learnt from patients when they complain, and how can these
findings inform service improvement in hospitals? It has been well articulated
that before complaints can be used as part of a strategy to effectively inform
health service improvement, an understanding of the true efficacy of the
Chapter 1: Overview of the Study
7
complaints handling process from the patient‘s perspective must be gained
(Bark, Vincent, Jones & Savory, 1994; Friele, Sluijs, 2006; Friele, Sluijs, &
Legemaate, 2008; Vincent & Coulter, 2002; Wal & Lens, 1995).
This study uses a qualitative design, with a focus on the interpretation of
a human phenomenon (Denzin & Lincoln, 2005; Heath, 1997). Considering the
primary aim of this study, the philosophy of phenomenology underpinned by the
Heideggerian perspective was selected as the most appropriate design to use
(Denzin & Lincoln, 2005; Warren & Karner, 2005).
An important aspect that influenced the use of a Heideggerian approach
stemmed from the discussions that developed the research questions for this
study. Within this methodological approach it is common when developing
research questions that they should arise, or be drawn, from a personal or
professional question (Dealey, 2003). The case for the focus of this study arose
from a professional perspective and is presented in the following personal
reflections.
1.2.1. Personal Reflections
My approach to this study is influenced by twenty-nine years of
experience as a nurse, with fifteen of those years being in senior health
management roles. Throughout that time I have repeatedly witnessed the
detrimental effects that can occur to our patients when complaints are handled
poorly. On many of those occasions I have been tasked with ―fixing‖ the
situation. For example, as a newly appointed Nurse Unit Manager to a Medical
Chapter 1: Overview of the Study
8
and Surgical Unit that had been labeled as the worst performing unit in the
hospital in terms of the number of complaints that had been lodged by patients,
the direction was to ―fix it‖. While the journey was at times difficult, within
twelve months the Chief Executive Officer was praising the performance of the
unit and stating in the hospital newsletter ―(X) Ward has the oldest equipment
and is in need of the greatest repair, yet despite these obstacles it has the least
amount of complaints and greatest level of patient satisfaction‖. This is just one
event in a series of many throughout my career. With this level of exposure and
involvement in change management and implementing improvement initiatives I
can categorically state that patient satisfaction, minimising adverse events and
reducing complaints is attainable.
1.3. SIGNIFICANCE OF THE STUDY
The research aims to fill some of the knowledge gaps identified in the
literature and it is significant as it presents a unique approach to determining
what can be learnt from patients when they complain. It uses a hermeneutic,
Heideggerian approach, underpinned by Lazarus‘ cognitive emotive model of
coping, to examine the narratives of the in-depth interviews.
This process has not been used before to examine the process associated
with patients complaining. This research has the potential to assist hospitals to
gain an understanding of how complaints handling processes may affect their
patients. While the narratives of the participants of this study have not identified
individual hospitals in Queensland, they provide generalised information that
Chapter 1: Overview of the Study
9
hospitals can use to assist them to effectively evaluate their own outcomes in
terms of complaints handling. This research is significant to the fields of
quality, patient safety, consumer advocacy and organisational learning as the
outcomes have the potential to inform service improvement processes leading to
improved satisfaction for patients. The research also examines the processes and
systems that have perhaps hindered, rather than supported, the resolutions of
complaints that have been made by patients.
The outcomes from this study will possibly stimulate action, improve
practice and overall achieve better outcomes for our patients.
1.4. STRUCTURE OF THE THESIS
Chapter 1-Overview
Chapter 1—Overview
Chapter 2—Literature Review
Chapter 3—Methodology, Design & Methods
Chapter 4—Findings
Chapter 5—Examination of Key Themes
References
Chapter 6—Conclusion & Recommendations
Table 1: Thesis Structure
Appendices
Chapter 1: Overview of the Study
10
This thesis comprises eight sections that are summarised on the following
pages.
1.4.1. Chapter 1: Overview
Chapter 1 provides an introduction to the importance of having an
effective complaint handling system. An important premise of this research is
that, for complaints to be used as a strategy to effectively inform health service
improvement, it is necessary to understand the complaints handling process from
the patient‘s perspective. Historical reflections of significant events that have
influenced health reform are highlighted and personal reflections are provided to
set the research scene.
1.4.2. Chapter 2: Literature Review
Chapter 2 presents key sources of information from an Australian
perspective to provide an understanding of how complaints handling has been
managed and evaluated in our health services.
Health reforms that have influenced the development of many complaints
handling processes are discussed. The factors that influence complaint behaviour are
dealt with as important aspects in understanding what motivates people to complain
in the first instance. Rather than evaluating complaints solely from a process and
systems base, Doig (2004) argues that if we were able to understand why the person
complained in the first place through understanding their expectations it would
assist us in the way we managed complaints, particularly at the first contact stage
when the complaint response has been triggered.
Chapter 1: Overview of the Study
11
The literature review identifies what resources have been developed to
manage health-care complaints in Queensland, Australia. Positive long-term
outcomes and organisational cultural shifts are less obvious in the literature, even
though many policies and processes are in existence.
1.4.3. Chapter 3: Methodology, Design and Methods
The research design and methodology for this study are discussed in
Chapter 3. The contextual underpinning used to explore the phenomenon of
complaining is introduced and the guiding questions used to focus the study are
explained. The philosophy of phenomenology is the design used and the
domains of phenomenological inquiry are discussed and illustrated to describe
the hermeneutic process. The orientations that can be undertaken within a
phenomenological exploration reflect a variety of different viewpoints that have
arisen through various philosophical underpinnings (Van Manen, 1997). The
phenomenological movement of hermeneutics has close association with the
philosophical perspectives of Heidegger (1889-1976), Gadamer (1900-2002) and
Ricouer (1913-2005). Essentially, Heidegger (1962) and his followers sought to
discover the all-encompassing question of the meaning of being. This road of
discovery elicited many concepts that are used as part of the phenomenological
language. For Heideggerian phenomenologists, the central core is the concept of
being and the term coined by Heidegger in 1962 known as dasein which is a
German word meaning existence. It is this ontology of one being in the world
that is the scaffold of Heidegger‘s hermeneutic approach (Plager, 1994; Van
Chapter 1: Overview of the Study
12
Manen, 1997; Wojnar & Swanson, 2007). Simply put, in this study it means
being there; it is a way to understand the experience of individuals who have
―been there‖ and become conscious of something that went wrong in their
lifeworld (Annells, 1996; Dreyfus, 1999).
1.4.4. Chapter 4: Findings
Chapter 4 presents the data collected using a phenomenological
hermeneutical methodology to explore the experience of patients who have made a
complaint about some aspect of their care while being inpatients in a Queensland
acute care hospital. Commencing with the demographic data and then providing a
step by step approach, this chapter presents findings collected from the narratives,
journal notes and thematic considerations of each of the participants. This chapter
details information about the participants and the findings from the first level data
analysis. A table is presented indicating a snapshot of the primary issues, the sub-
themes identified and the superordinate themes identified. A series of relational
themes that supported the interpretative data analysis process aided by
Leximancer™ data analysis software are also integrated into the findings.
Examples of the coding process are included in Appendix G. From the
coding process the following sub and superordinate thematic statements
emerged: (a) communication breakdown—ineffective communication, (b)
disparities in care & experience—treated with disrespect (c) dysfunctional
relationships—treatment issues, (d) information roadblocks—how to make a
complaint is not clear, (e) dereliction of care—perceptions of negligence. The
Chapter 1: Overview of the Study
13
thematic interpretation of the emotions that underpinned the participants‘
narratives are presented in this chapter
1.4.5. Chapter 5: Examination of Key Themes
Chapter 5 examines the five superordinate themes that emerged from the
participants‘ narratives following the data analysis. After the transcription
process the analysis process involved a deep immersion in the data collected
from the interviews. Several iterations of reading, re-reading, and identifying
themes, key words, and concepts were made until meaningful coding was
evident.
As part of the discussion process, close links will be drawn from the
literature review in Chapter 2. The discussion considers the questions posed in
Chapter 3 and the findings presented in Chapter 4.
1.4.6. Chapter 6: Conclusion and Recommendations
Chapter 6 includes conclusions drawn from the study, compared and
contrasted with significant literature—limitations of the study will be presented and
actions for future practice will be recommended.
Chapter 2: Literature Review
14
Chapter 2: Literature Review
2. INTRODUCTION
This chapter identifies key sources of information to provide an
understanding of how complaints handling has been managed and evaluated in
health services. A significant focus of this research is to capture and explore
patients‘ perceptions regarding satisfaction and dissatisfaction with health care
services in Australia. This review also examines how health reforms have
influenced the development of many complaints handling processes. It considers
whether there have been any identifiable lost opportunities as a result of health
reform recommendations. Finally, it examines what resources have been
developed to manage health care complaints in Queensland, and what the
potential organisational impacts are when complaints are handled incorrectly.
This review provides the knowledge base to contextualise the factors that
influence complaint behaviour, and the important roles these factors play in
understanding what patients expect when they make a complaint.
―The world is so dreadfully managed, one hardly knows to whom
to complain‖ Ronald Firbank (1886-1926)
Chapter 2: Literature Review
15
2.1. SEARCH STRATEGIES
The scope of this literature review represents a wide array of searches using
multiple search platforms. Literature was accessed using a range of dimensions of
complaints handling, for example: Safety and Quality, Marketing, Consumer
Advocacy and Management practices. The contextual and the methodological
underpinning of the study drew on literature from the Human Sciences arena.
An additional search strategy has been put in place to monitor the issue of
complaints being voiced about the Australian health care system, as well as
internationally. The outcome of these Google news alerts will be discussed in
Chapter 6.
2.2. DEFINING THE TERMS
2.2.1. Complaints Management
In 2006, Standards Australia released an updated version of the 1995
standard regarding complaints handling. The updated standard has been used
since its release to influence the development of many complaints resources over
the last decade, as was evidenced in several of the studies used in this review. In
reviewing the updated standard there appears to be no definition of ―complaints
management‖.
The terminology used in the updated standard focuses on the framework
of ―complaints handling‖, but put it in the context that complaints handling is
part of a bigger picture, namely the Quality Management System. This definition
immediately made sense. Perhaps this simple distinction of not classifying
Chapter 2: Literature Review
16
complaints as a stand-alone management system, which by definition
―complaints management‖ implies, was indeed significant. Truly understanding
and embracing the part ―complaints handling‖ plays in the bigger picture of an
effective organisation may go a long way to establishing this process as part of
the organisational culture, and not simply as a stand-alone management system.
A complaint, according to the 2006 standard, is an ―expression of
dissatisfaction made to an organisation, related to its products/service, or the
complaints-handling process itself, where a response or resolution is explicitly or
implicitly expected‖. The handling of the complaint refers to the ―overall
intentions and direction of the organisation related to complaints handling, as
formally expressed by top management‖ (ISO 10002:2004, 2006, p.11). This
distinction between complaints management and complaints handling has been
taken into consideration when reviewing the literature. Another distinction in
terminology that may assist in the analysis of the literature requires an
understanding of how health complaints are categorised.
2.2.2. Types of Complaints
From July 2006 the Health Quality and Complaints Commission for
Queensland (replacing a body previously known as The Health Rights
Commission) has had the authority to manage complaints under the legislation
Health Quality and Complaints Commission (HQCC) Act 2006. As an adjunct to
understanding the distinction between ―complaints management‖ and
―complaints handling‖, an understanding of what constitutes a complaint from a
Chapter 2: Literature Review
17
health perspective will help put the management and handling implications into
perspective.
The HQCC Act 2006 very clearly defines how complaints will be
viewed. Based on the intended expectations of this Commission to be
instrumental in restoring the trust of the health consumer of Queensland, the Act
defines health complaints as follows:
―…Health quality complaints are complaints about the quality of a
health service, including complaints about breaches of the provider‘s statutory
duty to have processes to improve the quality of health services. Any person,
including health service staff, may make a health quality complaint‖ And
―…Health service complaints are complaints by a consumer (or their
representative) about a health service provider‖ (Health Quality and Complaints
Commission Act 2006, p. 4).
A clear distinction that is evident in the Queensland HQCC Act 2006, as
opposed to other Acts which govern health services complaints bodies in
Australia, is the focus on quality as a driver of improvement. The word ―quality‖
is repeatedly used in the Queensland Act. Whilst the word ―quality‖ was
identified minimally in the South Australian and Western Australian Acts, it was
not used in the context of what defines a complaint. Extracts from those Acts are
presented in Table 2: Australian State and Territory Jurisdictions Managing
Complaints about Health Care.
Chapter 2: Literature Review
18
Table 2: Australian State and Territory Jurisdictions Managing Complaints about Health Care
State/
Territory
Governing
Body
Governing
Act
What Constitutes a Complaint
QLD Health Quality
and Complaints
Commission
Health Quality
and Complaints
Commission Act
2006
(1) A health quality complaint is a complaint about any of the following—
(a) the quality of a health service;
(b) a contravention of section 20(1);
(c) Matters relating to the provision of more than 1 health service.
(2) A health quality complaint may be about the provision of a health service to 1 or more
users.
(1) A health service complaint is a complaint—[s 37]
(a) that a provider acted unreasonably by not providing a health service for a user; or
(b) that a provider acted unreasonably in the way of providing a health service for a user; or
(c) that a provider acted unreasonably in providing a health service for a user; or
(d) that a provider acted unreasonably by denying or restricting a user‘s access to records
relating to the user in the provider‘s possession; or
(e) that a provider acted unreasonably in disclosing information relating to a user; or
(f) that a registered provider acted in a way that would provide a ground for disciplinary
action against the provider under the Health Practitioners (Professional Standards) Act 1999
or the Health Practitioner Regulation National Law; or
(g) that a public or private entity that provides a health service acted unreasonably by
(i) not properly investigating; or
(ii) Not taking proper action in relation to; a complaint made to the entity by a user about a
provider‘s action of a kind mentioned in paragraphs (a) to (f).
NSW Health Care
Complaints
Commission
Health Care
Complaints Act
1993-Section 7
(1) A complaint may be made under this Act concerning:
(a) the professional conduct of a health practitioner (including any alleged breach by the
health practitioner of Division 3 of Part 2A of the Public Health Act 1991 or of a code of
conduct prescribed under section 10AM of that Act), or
(b) A health service which affects the clinical management or care of an individual client.
(2) A complaint may be made against a health service provider.
(3) A complaint may be made against a health service provider even though, at the time the
complaint is made, the health service provider is not qualified or entitled to provide the health
Chapter 2: Literature Review
19
Table 2: Australian State and Territory Jurisdictions Managing Complaints about Health Care
State/
Territory
Governing
Body
Governing
Act
What Constitutes a Complaint
service concerned.
NT Health and
Community
Services
Complaints
Commission
Health and
Community
Services
Complaints Act
1998
A complaint may be made in respect of one or more of the following:
(a) that a provider acted unreasonably by not providing a health service or community service;
(b) that the provision of a health service or community service or a part of a health service or
community service was not necessary;
(c) that a provider acted unreasonably in providing a health service or community service;
(d) that a provider acted unreasonably in the manner of providing a health service or
community service;
(e) that a provider acted unreasonably by denying or restricting a user access to his or her
records that were in the provider's possession;
(f) that a provider acted unreasonably by not making available to a user information about the
user's condition that the provider was able to make available;
(g) that a provider acted unreasonably in disclosing information in relation to a user;
(h) that a provider or manager acted unreasonably in respect of a complaint made by a user
about the provider's action that is of a kind referred to in this section by:
(i) not taking, or causing to be taken, proper action in relation to the complaint; or
(ii) not properly investigating the complaint or causing it to be properly investigated;
(j) that a provider acted in disregard of, or in a manner inconsistent with, any of the matters
that the Commissioner may have regard under section 5 in determining whether or not a
provider has acted reasonably in providing a health service or community service;
(k) That an applicable organisation failed to comply with the Carers Charter.
SA Health and
Community
Services
Complaints
Commissioner
Health and
Community
Services
Complaints Act
2004
The objects of this Act are—
(a) to improve the quality and safety of health and community services in South Australia
through the provision of a fair and independent means for the assessment, conciliation,
investigation and resolution of complaints; and
(b) to provide effective alternative dispute resolution mechanisms for users and providers of
health or community services to resolve complaints; and
(c) to promote the development and application of principles and practices of the highest
Chapter 2: Literature Review
20
Table 2: Australian State and Territory Jurisdictions Managing Complaints about Health Care
State/
Territory
Governing
Body
Governing
Act
What Constitutes a Complaint
standard in the handling of complaints concerning health or community services; and
(d) to provide a scheme that can be used to monitor trends in complaints concerning health or
community services; and
(e) to identify, investigate and report on systemic issues concerning the delivery of health or
community services.
Section 25—Grounds on which to make a complaint
TAS Health Complaints
Commissioner Health
Complaints Act
1995
Making a complaint (a) a health service provider acted unreasonably by not providing a health service;
(b) the provision of a health service or of part of a health service was not necessary;
(c) a health service provider acted unreasonably in the manner of providing a health service;
(d) a health service provider failed to exercise due skill;
(e) a health service provider failed to treat a health service user in an appropriate professional
manner;
(f) a health service provider failed to respect a health service user's privacy or dignity;
(g) a health service user was not provided–
(i) in language and terms understandable to the user, with sufficient information on the
treatment and health services available to enable the user to make an informed decision; or
(ii) with a reasonable opportunity to make an informed choice of the treatment or services
available; or
(iii) with adequate information on the availability of further advice on the user's condition or
of relevant education programmes; or
(iv) with adequate information on the treatment or services received; or
(v) with any prognosis that it would have been reasonable for the user to be provided with;
(h) a health service provider acted unreasonably by–
(i) denying a health service user access to, or restricting the user's access to, records relating to
the user that were in the provider's possession; or
(ii) not making available to a health service user information about the user's condition that
the health service provider was able to make available;
Chapter 2: Literature Review
21
Table 2: Australian State and Territory Jurisdictions Managing Complaints about Health Care
State/
Territory
Governing
Body
Governing
Act
What Constitutes a Complaint
(i) a health service provider acted unreasonably in disclosing information in relation to a
health service user;
(j) a health service provider acted unreasonably by not taking proper action in relation to a
complaint made to him or her by the user about a provider's action of a kind referred to in this
section;
(k) a health service provider acted in any other manner that was inconsistent with the Charter.
VIC Health Services
Commissioner Health Services
(Conciliation
and Review) Act
1987
What may be included in a complaint
(1)A user or a user's representative may complain to the Commissioner if the complaint is that—
(a)a provider has acted unreasonably by not providing a health service for the user; or
(b)a provider has acted unreasonably in the manner of providing a health service for the user;
or
(c)a provider has acted unreasonably in providing a health service for the user; or
(d)a public or private health care institution has acted unreasonably by not properly
investigating, or not taking proper action upon, a complaint made to the institution by a user
about a provider's action which is of a kind mentioned in paragraphs (a) to (c).
(2)A complaint may be made under sub-section (1) if the complaint is that a provider has
acted unreasonably in any of the ways set out in that sub-section by not following the guiding
principles, but that sub-section is not limited to those kinds of complaints.
(3)A complaint cannot be made under sub-section (1) if the complaint concerns a matter that
could be the subject of a complaint under the Health Records Act 2001.
(4)A complaint may be made under sub-section (1) by a user's representative in relation to a
user who has died whether it is alleged in the complaint that the provider acted unreasonably
during the lifetime or after the death of the user.
WA Office of Health
Review Health and
Disability
Services
(Complaints)
Act 1995
(1)For the guidance of providers it is declared that health services should be provided so as to
promote — quality health care
What Complaints can be about:
(1)A complaint must allege that one or more of the following has occurred —
(a)a provider has acted unreasonably by not providing a health service for the user;
Chapter 2: Literature Review
22
Table 2: Australian State and Territory Jurisdictions Managing Complaints about Health Care
State/
Territory
Governing
Body
Governing
Act
What Constitutes a Complaint
(b)a provider has acted unreasonably in the manner of providing a health service for the user,
whether the service was requested by the user or a third party;
(c)a provider has acted unreasonably in providing a health service for the user;
(d)a provider has acted unreasonably by denying or restricting the user‘s access to records
kept by the provider and relating to the user;
(e)a provider has acted unreasonably in disclosing or using the user‘s health records or
confidential information about the user;
(f)a manager has acted unreasonably in respect of a complaint made to an institution by a user
about a provider‘s action which is of a kind mentioned in paragraphs (a) to (e) by —
(i)not properly investigating the complaint or causing it to be properly investigated; or
(ii)not taking, or causing to be taken, proper action on the complaint;
(g)a provider has —
(i)acted unreasonably by charging the user an excessive fee; or(ii)otherwise acted
unreasonably with respect to a fee;
(h)a provider that is an applicable organisation as defined in section 4 of the Carers
Recognition Act 2004 has failed to comply with the Carers Charter as defined in that section.
Sources: (Queensland, Health Quality and Complaints Commission Act 2006; New South Wales, Health care Complaints Act 1993; Northern
Territory of Australia, Health and Community Services Complaints Act 1998; South Australia, Health and Community Services Act 2004; Tasmania,
Health Complaints Act 1995; Victoria, Health Services (Conciliation and Review) Act 1987; Western Australia, Health and Disability Services
(Complaints) Act 1995).
Chapter 2: Literature Review
23
The link between quality and complaints that is reflected in the HQCC
Act 2006 is likely to drive the quality agenda in Queensland. The relevance and
the importance of having quality principles to underpin organisational
improvements will be discussed in further detail in chapters 5 and 6 in relation to
the use of a patient-centred approach to achieve quality outcomes for all
stakeholders.
2.3. IMPACT OF COMPLAINTS HANDLING
As discussed in Chapter 1, the importance of the information that can be
ascertained from complaints data cannot be underestimated. It is the opinion of
this author that most health care organisations would be able to confirm the
relevance of this statement and be able to present complaint data on cue.
However, can the same be said regarding the quality and the analysis of the data
being collected?
The majority of research into complaints handling has focused
predominately on the complaining consumer, and analysing findings from
satisfaction surveys. While recent studies, such as by Bodey and Grace (2006),
identify significant issues between the complaining and non-complaining
consumer from a marketing perspective, there is minimal evidence to date to
confirm that the true impact of this phenomenon has been realised from a health
care service and a patient‘s perspective.
Chapter 2: Literature Review
24
2.4. COMPLAINTS RESEARCH
There is certainly no shortage of information regarding the insights into
why consumers complain. Marketing and quality management theories are
grounded in understanding the impact that complaints and dissatisfaction with
service delivery can have on an organisation (Chulmin et al, 2003; Davidow,
2003; Deming, 1986; Gilmour & Hunt, 1998; Nyer, 2000; Stauss, 2002). The
information presented by the authors listed above all postulate the premise that
two thirds of consumers do not complain when they are dissatisfied. While this
fact can be validated from a marketing and quality management perspective,
there is minimal empirical evidence to suggest what this number could be when
attributed to health service and patients.
Internationally Gilly, Stevenson, and Yale (1991) reported that by the
end of the 1980s there were at least five hundred completed studies from a cross-
section of industries related to this area of inquiry. Unfortunately, Australia‘s
contribution to this body of work for health services research in that same time
period was very limited. Draper and Hill (1995) detailed fourteen studies up to
1994, mainly using qualitative methodology conducted on consumer satisfaction
in different health settings around Australia. Gilly et al. (1991) and Draper and
Hill‘s (1995) work supports the notion that the effective management of
complaints handling needs to be better understood internally within the
organisation for it to be truly effective.
Chapter 2: Literature Review
25
After reading the earlier work conducted by Draper in 1997, and her
presentation of findings, the following table (Table 3) was developed. Entitled
Australian Health Care Consumer Satisfaction Studies, Table 3 provides a
snapshot of research conducted, researcher or report owner, what states have
been involved in consumer complaints research and their significant findings
over the last twenty years. Following the presentation of this information in
tabular form the studies will be considered in more detail, in particular to reveal
the extent of research it has captured and explored patients‘ perceptions
regarding satisfaction and dissatisfaction with health care services in Australia.
Chapter 2: Literature Review
26
Table 3: Australian Health Care Consumer Satisfaction Studies 1989-2009
2.4.1. Australian Health Care Consumer Satisfaction Studies 1989-2009 (including timeline 1989-94 presented by Draper,1997)
Num Year State & Report
Owner if
applicable
Report Identifier/Author Target Sample & General Information Qual Quant
Type, Focus, Conclusion
41 2009 SA Kathy Stiller,
Grace Cains,
Craig Dury. Evaluating inpatient satisfaction
with a physiotherapy service: A
rehabilitation centre survey.
The purpose of this study was to
determine inpatients‘ levels of
satisfaction with a physiotherapy service
at one rehabilitation centre in South
Australia.
106 of 122 eligible inpatients completed
a purpose-designed survey. Analyses
were predominantly descriptive in
nature.
√ Observational study
The findings promoted confidence for the service
that a high standard of care was provided to
inpatients at the rehabilitation centre studied.
The survey concluded that it was relatively
straightforward to conduct in practice and has
identified areas where the service can be improved.
40 2009 SA James Allan,
Peter Schattner,
Nigel Stocks,
Emmae Ramsay. Does patient satisfaction of general
practice change over a decade?
The Patient Participation Program (PPP)
was a patient satisfaction survey
endorsed by the Royal Australian
College of General Practitioners and
designed to assist general practitioners in
continuous quality improvement (CQI).
The survey was undertaken by 3500
practices, and over a million patients
between 1994 and 2003. This study
aimed to use pooled patient questionnaire
findings to investigate changes in
satisfaction with primary care over time
√ The findings of 10 years of PPP surveys were
analysed with respect to 10 variables including the
year of completion, patient age, gender, practice
size, attendance at other doctors, and whether the
practice had previously undertaken the survey.
Comparisons were made using Logistic Generalised
Estimating Equations.
There was a very high level of satisfaction with
general practice in Australia (99% of respondents)
Participants were shown to have higher levels of
satisfaction if they were male, older, did not attend
other practitioners or the practice was small in size.
39 2008 NSW Cathryn Finny-Lamb,
Marijke Boers,
Angela Owens,
Jan Copeland,
Tanya Sultana. Exploring experiences and attitudes
about health care complaints
Stratified purposive sampling strategy
was used to enable comparison of the
opinions of staff and clients of the
Opioid Treatment Service. A total of 13
women and 10 health staff participated in
the study.
√ Semi-structured interviews were conducted.
A multidisciplinary team conducted a thematic
analysis of the transcripts.
Findings indicated that the issues that prevented
women from making complaints included the
anticipation of not being taken seriously, the fear of
repercussions including infant removal, and Page 31
Chapter 2: Literature Review
27
Table 3: Australian Health Care Consumer Satisfaction Studies 1989-2009
2.4.1. Australian Health Care Consumer Satisfaction Studies 1989-2009 (including timeline 1989-94 presented by Draper,1997)
Num Year State & Report
Owner if
applicable
Report Identifier/Author Target Sample & General Information Qual Quant
Type, Focus, Conclusion
among pregnant women, mothers
and staff at an Opioid Treatment
Service.
practical difficulties in making written complaints.
Staff reported that complaints at the dosing window
were often delivered emotively and could be
personalised.
38 2008 NSW P W Garrett,
H.G Dickson,
L Young,
A Klinken-Whelan.
"The Happy Migrant Effect":
perceptions of negative experiences
of healthcare by patients with little
or no English: a qualitative study
across seven language groups.
The reports of experiences from 49
patients of a tertiary referral hospital
were analysed using grounded theory
methods applied to translate the
transcriptions from focus groups held
with discharged patients in seven
languages.
√ Some immigrant patients with poor language skills
might not report serious problems with healthcare
delivery. In all patients in this study where
problems with healthcare were reported, the events
were considered to be largely preventable by
appropriate language facilitation, patient and family
involvement, and provider respect and compassion.
37 2008 QLD Andrew Fallon,
Stephen Gurr,
Mary Hannan-Jones,
Judith D Bauer. Use of the acute care hospital
foodservice patient satisfaction
questionnaire to monitor trends in
patient satisfaction with foodservice
at an acute care private hospital.
Three one-day surveys of foodservice
satisfaction were conducted in 2003–05
from an acute care 440-bed private
Australian hospital. The Acute Care
Hospital Foodservice Patient Satisfaction
Questionnaire (ACHFPSQ) contains 18
statements.
√ A total of 223 surveys were collected, statistical
analysis was carried out using SPSS. The
(ACHFPSQ) can be used to determine trends in
foodservice satisfaction and identify areas to target
for quality improvement initiatives. The
staff/service issues were the most positively rated
and food quality the least positively rated. Patients‘
expectations of the foodservice were significantly
associated with overall satisfaction.
36 2008 VIC Anna Ekwall,
Maria Gerdtz,
Elizabeth Manias.
The influence of patient acuity on
Data were collected in an Australian
metropolitan teaching hospital with
about 32,000 visits to the emergency
department each year. The Consumer
√ Prospective cross-sectional survey design with a
consecutive sampling technique.
Significant differences in perceptions of patient
urgency between accompanying persons and nurses
Chapter 2: Literature Review
28
Table 3: Australian Health Care Consumer Satisfaction Studies 1989-2009
2.4.1. Australian Health Care Consumer Satisfaction Studies 1989-2009 (including timeline 1989-94 presented by Draper,1997)
Num Year State & Report
Owner if
applicable
Report Identifier/Author Target Sample & General Information Qual Quant
Type, Focus, Conclusion
satisfaction with emergency care:
perspectives of family, friends and
carers.
Emergency Satisfaction Scale was used
to measure satisfaction with nursing care.
The aim of this study was to investigate
the factors that influence satisfaction
with emergency care among individuals
accompanying patients to the ED and to
explore agreement between the triage
nurse and accompanying person
regarding urgency of the patient‘s
condition.
were found. Those people accompanying patients
of a higher urgency were significantly more
satisfied than those accompanying patients of a
lower urgency. These findings were independent of
real waiting time or the accompanying person‘s
knowledge of the patients‘ triage status. In addition,
older accompanying persons were more satisfied
with emergency care than younger accompanying
persons.
35 2006 National Amanda Henderson.
Perspectives and practice: the
satisfaction construct.
A convenience sample of 29 staff
representing 17 hospitals from across
Australian States and Territories
participated in a series of focus groups.
√ Ethnographic study that explored Australian health
practitioners' understanding of ‗patient satisfaction‘.
Systematic ethnographic summary and content
analysis revealed 15 themes which health
practitioners considered important in making a
patient‘s hospital stay satisfactory. Participants in
this research, who were known to be involved in
measuring patient satisfaction with particular
services, were not able to define or agree on the
meaning of patient satisfaction.
34 2006 VIC KB Smith,
JS Humphreys,
JA Jones.
Essential tips for measuring levels
of consumer satisfaction with rural
health service quality.
This study compared two methods of
analysing rural consumers‘ satisfaction
with healthcare services. Three rural
communities in western NSW and eight
communities in north-west Victoria were
sampled.
√ Householders in both studies rated their satisfaction
with regard to the availability, accessibility, choice,
continuity and affordability of health services.
Levels of satisfaction were highest in both states in
relation to the extent to which their day to day
health needs can be met locally.
Chapter 2: Literature Review
29
Table 3: Australian Health Care Consumer Satisfaction Studies 1989-2009
2.4.1. Australian Health Care Consumer Satisfaction Studies 1989-2009 (including timeline 1989-94 presented by Draper,1997)
Num Year State & Report
Owner if
applicable
Report Identifier/Author Target Sample & General Information Qual Quant
Type, Focus, Conclusion
33 2006 VIC Judith A Jones,
Terri A Meehan-Andrews,
Karly B Smith,
John S Humphreys,
Lynn Griffin,
Beth Wilson.
There’s no point complaining,
nothing changes: rural disaffection
with complaints as an improvement
method.
Eight communities in the Loddon-Malle
region of Victoria
983 householders responsible for the
health care of household members
responded to a mailed questionnaire
√ The first purported empirical survey of rural
consumer behaviour relating to complaints about
health services in Australia. Responses to open-
ended questions were coded using qualitative
content analysis. Rural health consumers reported
that health care providers are not viewed by them as
being responsive to their complaints.
Specific note: that under-representation of
complaints from the rural sector is not a measure of
satisfaction.
32
2006 VIC David Taylor,
Marcus P Kennedy,
Elizabeth Virtue,
Geraldine McDonald.
A multifaceted intervention
improves patient satisfaction and
perceptions of emergency
department care.
Study was undertaken in the emergency
department of the Royal Melbourne
Hospital, a university-affiliated centre in
Victoria, Australia, that treats
approximately 47 000 patients per year
with relatively little seasonal variation.
A total of 321 and 545 patients returned
questionnaires in the pre- and post-
intervention periods.
√ Prospective intervention trial that evaluated
patient satisfaction before and after introduction of
the study intervention.
Aimed to evaluate the effectiveness of a
multifaceted intervention, targeting staff–patient
communication, in improving emergency
department patient satisfaction.
Significant improvements were identified in a
variety of patient satisfaction measures were
achieved with an intervention comprising staff
communication workshops, a patient education
film, and a patient liaison nurse.
31 2006 QLD
Queensland Health State-wide
Patient Satisfaction Survey: State
Report
Hospitals included in the survey were
grouped into 5 peer groups providing
similar services and to do a comparison
from within peer group perspective.
√ 33,173 questionnaires were mailed to patients
between March and August 2005.
16,705 completed returned questionnaires = approx
50% return rate
Chapter 2: Literature Review
30
Table 3: Australian Health Care Consumer Satisfaction Studies 1989-2009
2.4.1. Australian Health Care Consumer Satisfaction Studies 1989-2009 (including timeline 1989-94 presented by Draper,1997)
Num Year State & Report
Owner if
applicable
Report Identifier/Author Target Sample & General Information Qual Quant
Type, Focus, Conclusion
30 2005 VIC Judith Jones,
John S Humphreys,
Beth Wilson.
Do health and medical workforce
shortages explain the lower rate of
rural consumers’ complaints to
Victoria's Health Services
Commissioner?
All health care providers practising in
Victoria were included in this review.
De-identified records of all closed
consumer complaints made to the Health
Services Commissioner, Victoria,
between March 1988 and April 2001 by
Victorian residents (13 856 records)
√ Ecological study incorporating consumer
complaint, population and workforce distribution
data sources. To identify which explanations
account for lower rural rates of complaint about
health services. No consistent relationship was
observed between community size and either
degree of under-representation of complaints
against any category of provider, or the proportion
of serious or substantial complaints.
29 2004 VIC David Taylor,
Rory S Wolfe,
Peter A Cameron.
Analysis of complaints lodged by
patients attending Victorian
hospitals, 1997–2001.
Analysis of complaints lodged by
patients attending Victorian hospitals
representing 67 hospitals (metropolitan,
25; rural, 42) (62 public and 5 private) in
Victoria.
√ Retrospective analysis of complaints, lodged with
the Victorian Health Complaint Information
Program (January 1997—December 2001).
Concluded an overall complaint rate of 1.42
patients/1000 patients during the study period.
28 2004 VIC Helen Varney,
Maura Conneely,
Suzanne Phillips.
Breast screen Victoria using
consumer groups in an audit of
complaints.
Complaints settled during the period
from April–June 2004 were reviewed. A
report compiled all the findings and
further analysis was completed across
multiple sites. The goal of this study was
to identify service improvement.
√ √ Pilot Study-Audit-Retrospective analysis of
complaints date. Interviews conducted with service
providers.
The findings from the pilot study confirmed that
collaboration between Managers and Consumers is
a viable method of complaints review.
27 2004 VIC
Health Issues Centre
Bringing in the consumer
perspective: consumer experiences
of complaints processes in
Victorian health practitioner
300 complainants from de-identified lists
supplied by the Boards were contacted-
60 participants were selected. Central
focus of the research was to capture what
the ‗flavour‘, depth and breadth of
√ √ Mixed method
Consumer experiences of complaints processes in
Victorian Health Practitioner Registration Boards.
Chapter 2: Literature Review
31
Table 3: Australian Health Care Consumer Satisfaction Studies 1989-2009
2.4.1. Australian Health Care Consumer Satisfaction Studies 1989-2009 (including timeline 1989-94 presented by Draper,1997)
Num Year State & Report
Owner if
applicable
Report Identifier/Author Target Sample & General Information Qual Quant
Type, Focus, Conclusion
registration boards. complainant experiences and their
meanings
26 2003 VIC Judith A Jones,
Beth Wilson,
John S Humphreys,
Philip Punshon,
Lynn Griffin.
Rural consumers’ complaints about
health services.
Rural consumers‘ complaints about
health services.
√ Preliminary findings from a study investigating the
existence of urban-rural differences in the numbers
and characteristics of complaints to the Health
Services Commissioner. The specific objectives of
the study were to: identify the existence of any
urban-rural differences in rates of complaint about
health services across Victoria.
25 2002 VIC David Taylor,
Rory Wolfe,
Peter A Cameron.
Complaints from emergency
department patients largely result
from treatment and communication
problems.
2419 Emergency patients complained
about a total of 3418 separate issues
Findings obtained from the Health
Complaint Information program (Health
Services Commission).
√ Retrospective analysis of patient complaints from
36 Victorian Emergency Departments during a 61
month period. The identification of patients‘
complaints have driven improvement initiatives,
despite several improvements communication
issues remain significant.
24 2001 National Greg Ford
Measuring consumer feedback:
examples of patient surveys in
Australian public hospitals:
The project arose from inquiries to the
National Resource Centre for Consumer
Participation in Health from people
wanting information about patient
satisfaction surveys and to assist them in
developing their hospital‘s patient
satisfaction survey.
√ √ The study focus was to collect, analyse and
describe the key features of selected examples of
patient satisfaction surveys used in Australian
public hospitals.
Patient satisfaction surveys are just one of a
number of methods used by health services to seek
consumer feedback and are most effective when
used in conjunction with other research methods.
2001 SA
Kathryn Anderson,
Deidre Allan,
Flinders Medical Centre (FMC), a 412-
bed university teaching hospital and the √ Retrospective analysis of complaints data. 30
month study of patient complaints at a major
Chapter 2: Literature Review
32
Table 3: Australian Health Care Consumer Satisfaction Studies 1989-2009
2.4.1. Australian Health Care Consumer Satisfaction Studies 1989-2009 (including timeline 1989-94 presented by Draper,1997)
Num Year State & Report
Owner if
applicable
Report Identifier/Author Target Sample & General Information Qual Quant
Type, Focus, Conclusion
23 Paul Finucane.
A 30-month study of patient
complaints at a major Australian
hospital.
major public hospital facility in the
southern region of Adelaide, South
Australia.
30-month period, between January 1998
and July 2000.
Australian hospital
A total of 1308 complaints, concerning the care of
1267 patients, were received. The complaint rate
was 1.12 per 1000 occasions of service. In all, 57%
of complaints were lodged by advocates and 71%
of complaints related to poor communication or to
the treatment provided. In 97% of occasions, an
explanation and/or an apology resulted. To date, no
complaint has proceeded to litigation.
22 2000 SA
Kathryn Anderson,
Deidre Allan,
Paul Finucane.
Complaints concerning the hospital
care of elderly patients: a 12-month
study of one hospital’s experience.
Complaints concerning the hospital care
of elderly patients aged 65 years and
above:
In 1 year—hospital provided 383,365
occasions of service and received 505
complaints, overall complaint rate of
1.32/1000 occasions of service – Target
sample represented 127 complaints
=1.44/100.
√ A 12-month (June 98-July 99) study of one
hospital's experience.
Descriptive analysis of computerised data of
complaints lodged.
Concluded that complaints concerning older
patients in hospitals are as common as those
concerning younger patients.
21 1999 National Ross Wilson,
Bernadette T Harrison,
Robert W Gibberd,
John D Hamilton.
An analysis of the causes of adverse
events from the Quality in
Australian Health Care Study.
2353 Adverse events (AEs) previously
reported by the Quality in Australian
Health Care Study (QAHCS) were
reviewed.
√ A qualitative approach was used to develop
categories for human error and for prevention
strategies to minimise these errors. These categories
were then used to classify the Adverse Events
identified in the QAHCS, and the findings were
analysed with previously reported preventability
and outcome data.
20 1999 NSW Ann E Daniel,
Raymond J Burn,
Random sample of complaints lodged
with the New South Wales Health Care √ 32-item questionnaire – Patients‘ complaints about
medical practice. Examination of the experience of
Chapter 2: Literature Review
33
Table 3: Australian Health Care Consumer Satisfaction Studies 1989-2009
2.4.1. Australian Health Care Consumer Satisfaction Studies 1989-2009 (including timeline 1989-94 presented by Draper,1997)
Num Year State & Report
Owner if
applicable
Report Identifier/Author Target Sample & General Information Qual Quant
Type, Focus, Conclusion
Stefan Horarik
Patients’ complaints about medical
practice.
Complaints Commission (HCCC)
between February 1996 and August
1997. Sample 500 – Participants = 290
healthcare complainants, and their satisfaction or
dissatisfaction with the process and outcome of
lodging a formal complaint.
19 1999 VIC Barbara A Davis,
Elaine Duffy.
Patient satisfaction with nursing
care in a rural and an urban
emergency department.
The sample consisted of 103 rural and
urban emergency patients. √ Qualitative analysis of two open-ended questions
regarding what respondents liked best about the
experience and what could have made the
experience better, produced four and six themes,
respectively. Conclusions indicated the need for
more research comparing rural and urban
emergency patients and patients of different
cultures.
18 1998 National David Cooper.
Anne Jenkins.
Obtaining consumer feedback from
clients of home based care services:
A review of the literature.
Twenty-four Australian consumer survey
studies published since 1996 were
reviewed
Prepared for HACC Officials in relation
to the HACC Service Standards
Consumer Appraisal Data Development
Project
√ Review of the literature: Obtaining consumer
feedback from clients of home based care services.
Annotated bibliography of studies presented with
characteristics of the population to which each
survey method is applied and the nature of the
measures are described.
17 1997 National
Mary Draper.
Involving consumers in improving
hospital care: Lessons from
Australian hospitals.
Commonwealth Department of
Health and Family Services.
literature review of consumer
participation
analysis of feedback mechanisms from
Australia and overseas analysis of
findings from feedback from consumers
in Australia and overseas
√ Case studies ―Lessons from Australian Hospitals‖
The primary conclusion from this study supported
that health services needed to use a variety of
methods when they were evaluating consumer
perceptions of their services.
16 1996 VIC David Douglas,
Robyn D Harrison.
Turning around patient complaints
One Australian regional hospital
describes the introduction of a different
system for handling complaints from
√ Anecdotal evidence only of effectiveness post
implementation of statement of patient expectations
tool developed to categorise and respond to
Chapter 2: Literature Review
34
Table 3: Australian Health Care Consumer Satisfaction Studies 1989-2009
2.4.1. Australian Health Care Consumer Satisfaction Studies 1989-2009 (including timeline 1989-94 presented by Draper,1997)
Num Year State & Report
Owner if
applicable
Report Identifier/Author Target Sample & General Information Qual Quant
Type, Focus, Conclusion
in a regional hospital.
patients.
It outlines the underlying philosophy of
the new system and the experiences of
the hospital as the new system matured.
complaints.
New position of Complaints Officer instead of
Public Relations Officer.
15 1995 National
Sophie Hill,
Mary Draper.
Consumers and general practice:
understanding and assessing
consumers’ experiences by using
patient satisfaction surveys.
Department of Human Services
and Health
Examination about what Australian
health care consumers have said and
written about their experiences with
hospitals.
Examination of a set of methodological,
organisational and policy issues in
relation to consumer feedback.
√ Evaluation Study
The role of patient satisfaction surveys in a national
approach to hospital quality management.
14 1995 National
Society of Consumer Affairs
Study of Consumer Complaint
Behaviour in Australia.
National Survey. In 1994, SOCAP
commissioned Technical Assistance
Research Programs (TARP) to conduct a
study of consumer complaint handling in
Australia
√ √ Household mail survey
Series of mini case studies of innovative complaint
handling practices.
13 1995 Common
wealth
(Multiple authors &
contributors)
(1995). Review of professional
indemnity arrangements for health
care professionals (Australia).
Compensation and professional
indemnity in health care: final
report, Commonwealth of Australia
Professional Indemnity review (PIR)
(supported 19 studies which had a
consumer focus regarding health care)
Most notable: Quality in Australian
Health Care Study 1992-95. 23
hospitals from NSW and 8 hospitals
from SA participated in the study
√ √ PIR Study commenced in 1991-1995
Adverse event rate of 16.6% with a 50% suggestion
of preventable events.
The Harvard Study conducted in the US was used
as a model
12
1994 National (Draper, 1997)
Consumers’ Health Forum
Held 30 consultations and public meetings High
users, socially disadvantaged, Aust. wide. √ Public meetings and focus groups on all aspects of hospital
care.
Chapter 2: Literature Review
35
Table 3: Australian Health Care Consumer Satisfaction Studies 1989-2009
2.4.1. Australian Health Care Consumer Satisfaction Studies 1989-2009 (including timeline 1989-94 presented by Draper,1997)
Num Year State & Report
Owner if
applicable
Report Identifier/Author Target Sample & General Information Qual Quant
Type, Focus, Conclusion
Included 3 meetings with people from NESB
11 1994 VIC
(Draper, 1997) Council on the Ageing 40-50 Consumers, as well as health workers
Older people, city & rural, Targeted people
from NESB
√ Focus groups and interviews re: Hospital discharge
planning.
10 1994 NSW
(Draper, 1997) Delegation of Seniors’
Organisations
208 Older people who had been in hospital √ Questionnaire re: Hospital discharge planning.
9 1994 VIC
(Draper, 1997) Gilley for Brotherhood of
St Laurence
146 Mothers, living on fringe of Melbourne and
Victorian provincial cities √ Interviews, demographic survey re: Hospital usage.
8 1994 National
(Draper, 1997) NHMRC W/party on
treatment for diagnosed breast cancer
46 publications Women from Australia, and
from N America, Europe. Mainly white, m/class. √ Personal accounts, letters systematic review of women’s
views. Covered all aspects of treatment, including hospital
care and radiotherapy.
7 1994 WA
(Draper, 1997) Health Consumers’
Council
932 People reading daily paper in Perth; no
demographic analysis. √ Short questionnaire in daily paper. Questions on care after
hospital stay; and feedback mechanisms.
6 1993 National
(Draper, 1997) Aust. Council on Social
Service
200 (approx.) People disadvantaged in terms of
health status. √ Focus groups covered hospital and general use
5 1993 SA
(Draper, 1997) NW Suburbs Health &
Social Welfare Council & Migrant
Health Services
293 consumers. Those using interpreters in
South Australia. 148 health workers √ Phone-in and survey.
4 1992 SA
(Draper, 1997) Marion Brighton Glenelg
Health & Social Welfare Council
Several hundred Consumers and carers using
mental health services √ Public meeting, Interviews, Workshops on Hospital care
covered by looking at system in general
3 1991 VIC/NSW
(Draper, 1997) Australian Pensioners’
& Superannuation’s Federation
142 Older people with diabetes and/or arthritis.
Sydney or Melbourne.2 groups from NESB.12
groups from hostels.
√ Focus groups on hospital care covered by looking at system
in general.
2 1991 SA
(Draper, 1997) Marion Brighton Glenelg
Health & Social Welfare Council
61 Mothers in region. √ Survey, group consultations re: Hospital and tests conducted
in pregnancy.
1 1989 SA
(Draper, 1997) Marion Brighton Glenelg
Health & Social Welfare Council
60 (mainly consumers) Mothers and some health
workers in region. √ Public meeting Re: Hospital care during pregnancy and
birth.
Chapter 2: Literature Review
36
2.4.2. Summary of Table 3
The studies presented in Table 3 represent a wide variety of
consumer/patient satisfaction outcomes that have been studied across a range of
health care sectors in Australia over a twenty year period. The studies considered
are representative of research that met the criteria to be included in this review.
These criteria include that the studies were conducted in Australia and focused on a
health care service, irrespective of the type of service they represented; and, research
was empirically based. Forty-one studies were reviewed, including the twelve
presented by Draper (1997).
Table 4: Literature Review—where studies were conducted
The location where the studies have been conducted throughout Australia
reveal a disparity in focus on this subject of consumer/patient satisfaction outcomes.
Queensland studies are certainly under-represented, which adds significance to the
relevance of this study. With respect to the empirical nature of the research, the
majority of the studies (68%) used a retrospective approach, such as
Chapter 2: Literature Review
37
questionnaires/surveys and case studies, to investigate their study area. Two of the
forty-one studies used a semi-structured interview approach, with neither of those
studies coming from Queensland. The remainder of the studies used a mixed
methodological approach. The rationale to undertake an in-depth interview
approach was influenced by the dearth of studies identified by this literature review
that were conducted using this method.
Of the forty-one studies identified, five distinct categories were recognised.
The majority of the studies (62%) were motivated to confirm satisfaction with the
particular service area. The next area of interest focused on evaluating quality or
change management initiatives (14%). The remainder of the studies included
investigating the identification of organisational impacts (10%), understanding the
influences on satisfaction (7%) and also two studies (7%) focused on examining the
experience of the complainant actually complaining. This review has identified that
there are no studies to date that have explored the issue of the complainants‘
experience of complaining using an in-depth interview approach. Nor has there been
any presentation of this study intent on representing Queenslanders who have been
inpatients in Queensland acute care hospitals. These insights add further value to the
significance of this study.
Chapter 2: Literature Review
38
2.5. COMPLAINTS HANDLING: A TWENTY YEAR PERSPECTIVE
1989-2009
2.5.1. Confirming Satisfaction with Service Areas
The measurement of patient satisfaction with health care services is a well
accepted strategy to evaluate the quality of care being delivered (Marcinowicz,
Chlabicz & Grebowski, 2009; Otani, Waterman, Faulkner, Boslough, Burroughs &
Dunagan, 2009). This is certainly not a new concept, as evidenced by the
contribution from Donabedian in 1966. Donabedian is noted for developing the
original quality framework that evaluates health services; he also repeatedly
cautioned against the measures that are used to validate quality of services. From his
identification of potential variables that could affect quality outcomes, he proposed
the following ―seven pillars of quality as being: efficacy, efficiency, optimality,
acceptability, legitimacy, equity and cost‖ as standards to measure quality outcomes
(Best, Neuhauser, 2004). These seven pillars can be evidenced in ―much of the
conceptual underpinnings for quality assessment in health systems [still] used
today‖ (Mullan, 2001, p. 138). Evidence of Donabedian‘s (1966) quality framework
will be sought in the studies included in this review.
The first purported quantitative study conducted in Australia to study the
behaviours associated with consumer complaints was undertaken in 1995 by the
Society of Consumer Affairs Professionals in Business Australia (SOCAP). At
that time, SOCAP reported that the better the complaints handling process, the
higher the level of satisfaction achieved by the customer. This study and
subsequent studies have used a cross-section of people representative of a
Chapter 2: Literature Review
39
variety of sectors. These studies have a clear message: there is a changing
landscape of complaints culture, and complaint handling should not be managed
by a specific department or an individual but rather, the responsibility must be
assumed by the organisation as a whole.
More recent studies conducted by SOCAP revealed that the basic
attitude toward complaints and the complaints handling processes in many
organisations has improved over time. However SOCAP Patron, Professor Allan
Fels, stated, in response to the findings, that Management knows that
―…satisfying customers is vitally important to their business, but clearly they
don‘t seem to know how‖ (Customer complaints, it’s still a business, 2005).
In the same period, another study was being conducted that can be
viewed as momentous in terms of the findings it presented, particularly for the
health industry. The subsequent domino effect that occurred across health care
in Australia as a result of the adverse findings from this study are still being
discussed and analysed today. The Professional Indemnity Review (PIR) study
was first commissioned in 1991 by the Commonwealth Government. The study
was commissioned to develop an understanding of the implications of financial
compensation as a direct consequence of a health consumer being involved in a
serious incident. The study lasted for more than four and a half years and
produced nineteen publications (PIR, 2006).
The significance of many of the publications appeared to be
overshadowed by one particular study that was used to investigate the causality
Chapter 2: Literature Review
40
and outcomes for patients which were involved in adverse events. Findings
from the Quality in Australian Health Care Study (QAHCS) 1995, regarding
preventable adverse events shifted the focus towards the safety of health
consumers. According to Van Der Weyden (1995, p. 453) ‗The first of June
1995 may well be recorded in the chronicles of Australian health care as a black
day for Australian hospitals‘.
This report has been used as a key source of information in the
development and understanding of the responsibilities and accountabilities that
health care providers have for the safety of health consumers (Douglas &
Harrison, 1996). Within the PIR study, recognition was assigned to the
importance of encouraging complaints. A critical safeguard was seen as the need
to have independent bodies to manage health consumer complaints. The findings
from the PIR study were the catalyst for what we know today as the Complaints
Commissions in each state and territory of Australia.
Four of the original six contributing authors of the 1995 QAHCS have
provided further insights into the original study. Firstly in 1999, Wilson,
Harrison, Gibberd, and Hamilton provided an analysis of the causes of the
adverse events reported in the QAHCS. This follow-up report was not an
extension of the previous author‘s findings but focused more on validating the
original findings. Blomberg (1996) reported that the original study in 1995
caused such extreme reactions because the findings and the recommendations
raised questions without providing sufficient answers. This may have been why
Chapter 2: Literature Review
41
the original contributors apparently saw a need to further validate their findings.
However, in this subsequent study they chose a qualitative approach, as opposed
to the original quantitative approach, to categorise the adverse events initially
reviewed. So, while the authors were able to offer some variation in the
potentially adverse events, the two findings cannot be compared because of the
different methodological approaches used in the two studies. And, perhaps the
intent was not to compare but to provide more richness to the initial quantitative
findings –unfortunately this cannot be confirmed. Wilson and Van Der Weyden
(2005) provided a further contribution and concluded 10 years on from the
QAHCS:
... That most patients in our healthcare system do not suffer preventable harm,
and receive good care. But it is still possible that up to 16% of hospitalised
patients will suffer an adverse event: 50% of these events will be preventable
and 10% of these preventable events will lead to permanent disability or death
... (p. 260)
In Victoria, a retrospective study was conducted of health complaints that
had been collated via the Health Complaint Information Program (HCIP) of the
Victorian Health Services Commissioner. This study involved a rich source of
data representing more than 13 million patients, from 67 hospitals throughout
Victoria. They were able to confirm an overall complaint rate of 1.42
patients/1000 patients during the study period of 1997-2001. However, there
were many confounding variables that needed to be addressed before this result
could be viewed definitively. These consisted primarily of issues related to the
Chapter 2: Literature Review
42
potential under-representation of the true number of complaints. The data only
represented the complaints fully lodged in the database, and did not take into
account any other collection method. Specific details, such as the age of the
complainant, could not be identified and there were issues with the completeness
of the information in the database. These types of issues must prompt caution in
a review of findings from complaints analysis, because the validity of the
mechanisms cannot be confirmed (Taylor, Wolfe, & Cameron, 2004).
This was also a key issue identified by Draper and Hill (1995) in their
study on the feasibility of a national approach to quality management being
achieved through the collection of satisfaction data. Their findings discussed the
difficulties associated with undertaking analysis of metrics without suitable data,
let alone unaggregated data that cannot be effectively analysed. They
recommended that, for complaints data to be valid, it is essential that
consideration should be applied to a system that will maximise the value of the
data collected. At that time in 1995, they reported that the health commissions
charged with managing health complaints on a state level were working towards
establishing some sort of consensus on how to collate and share this data.
Fifteen years on, each state is now able to comprehensively report on the
data it has collected; however, there has been no national consensus on how the
data could be collected and comparatively analysed to determine trends and
identify risks. This fact was also confirmed during a discussion about this thesis
intent with former Health Complaints Commissioner of Queensland, David
Chapter 2: Literature Review
43
Kerslake (personal communication, January 23, 2006). The point was raised
with the commissioner concerning Australia‘s lack of national consensus on how
to collect, report, and compare complaints data. He confirmed this point by
stating ... ―we do not have apples for apples to compare our complaints data,
when all the state commissioners meet for our regular discussions we only have
the opportunity to present what we do in our states‖. The discussion with the
commissioner revealed that this inability to share comparative data was
frustrating, but he also acknowledged that the complexities involved in
establishing a national consensus on how to handle, manage, and report
complaints was fraught with many difficulties.
However, as of July 1, 2010, after much debate and as a consequence of
the implementation of the Health Practitioner Regulation National Law Act 2009
(Act B), this weakness in the system is to be addressed by the implementation of
―nationally consistent arrangements for receipt of complaints and notifications
and dealing with the management of health, performance and conduct matters to
ensure protection of the public‖ (Health Practitioner Regulation National Law
Bill 2009, p. 5). The ability to comparatively analyse a large data set when a
national approach to complaints data is fully functional, will undoubtedly
provide significant information regarding trends and anomalies.
Draper and Hill (1995) discussed the importance of acknowledging that
data collected must be representative of the population under study. When we
look at a system that uses a large-scale comparative approach, understanding and
Chapter 2: Literature Review
44
reporting the findings needs to go beyond simply comparing the baseline data.
Complaint data can be flawed in its mechanisms to being able to factor and
redress all possible confounding variables so that the data is truly representative
of the target group we are looking at. Fieldman & Boyce (2002) supported by
Doig (2004) agree that getting the right information to ask before the data
collection occurs requires the complaint-handling process to be correct for the
target group.
An example to support how data collection and subsequent interpretation
can be skewed was apparent in the study conducted by Anderson, Allan, and
Finucane (2000). They undertook a descriptive analysis of prospectively
collected computerised data on complaints lodged by patients aged 65 years and
over for a 12-month period. The aim of the study was to determine whether the
same trigger factors of service dissatisfaction led to complaints by younger and
older patients alike. While the study concluded that there were commonalities in
the types of complaints concerning both young and elderly patients, one of the
confounding variables identified was not suitably explained. From the target
sample representing patients over 65 years of age, only 27% of the total
complaints lodged, came from the actual patient. The remaining complaints were
lodged by a variety of advocates, including relatives and hospital staff. While the
influence of the advocate was discussed in broad terms, there was no link made
between this and the findings. As the primary focus of this study was to identify
commonalities between complaints experienced among different age groups, the
Chapter 2: Literature Review
45
influence of potentially 73% ‗younger advocates‘ may influence the findings
reported in this study.
The same authors conducted another study in 2004, undertaking a
retrospective review of complaints data over a 30-month period. The goal of the
study was to create a profile of complainants, to determine the reasons for their
complaints, and the subsequent outcomes were analysed. This study offers
relevancy of information in the context of the hospital being able to report this
metric, but it has not provided any insights into whether the collection of this
data has benefited any stakeholders related to that hospital. The authors
concluded their study explaining that:
... the lack of published data with which to compare our study findings, it
appears that other institutions are either not collecting data concerning
complaints or are neglecting to publish such data. As a result, we are all denied
the opportunity to optimise the use of complaints as a quality improvement
tool... (Anderson, Allan, & Finucane, 2001, p.111)
While the ability to compare data and benchmark outcomes has still not
been fully realised, despite being discussed for over a decade, individual health
services can still contribute to the bigger picture by continuing to examine the
implications of complaints and how they affect their services and their
stakeholders. The paradigm shift must go beyond regurgitating complaints data
metrics in percentages per patient contact, towards a concerted effort to evaluate
what the complaints data is really saying about the organisation and how the
organisation should respond to the complaint. As the focus of many of the
Chapter 2: Literature Review
46
studies included in this review is very two-dimensional. They examine cause and
effect outcomes on a superficial level only, without considering the full effect of
actual and potential confounding variables. This leads to the following
conclusion.
Overall, the most significant quality measures identified in the studies
used in this review have focused on establishing or confirming efficacy and
efficiency of their service area. Minimal attention to other quality measures
identified by Donabedian (1966) is evident. Recent research by Stiller, Cains,
and Drury (2009) and Fallon, Gurr, Hannan-Jones and Bauer (2008) appear to be
representative of the type of individual studies being conducted by health
services throughout Australia. While both studies confirmed patient‘s
satisfaction with a physiotherapy service the food menu in one Australian
hospital, it must be considered that simply showing a high level of satisfaction
with one aspect of the service area may not be enough to prove quality (Otani, et
al. 2010).
2.5.2. Evaluation of Quality/Change Management Initiatives
While Donabedian (1966) is identified as being one of the earliest
proponents of measuring quality outcomes of a service, there was also a group
referred to as quality management gurus. Notable gurus included Juran and Deming
from America and Ishikawa and Taguchi from Japan. They influenced the
implementation of the Total Quality Management (TQM) movement globally in
most service areas (Gilmour & Hunt, 1998). Within the health care services in the
Chapter 2: Literature Review
47
late nineties a TQM approach was discussed as the core function of implementing
effective accreditation systems. The Australian Council on Healthcare Standards
(ACHS) Evaluation and Quality Improvement Program (EQuiP) is clearly
influenced by the TQM framework. The EQuiP program is used extensively
throughout Australian health services and the evaluation of initiatives implemented
is a key consideration in meeting the accreditation process (ACHS, 2006).
Figure 1: TQM Framework: Plan, Do, Check, Act Cycle
Source: (Lim, 2009).
A few of the studies reviewed did focus on the evaluation process to
validate initiatives; however, the essentials of the TQM framework as reflected in
Figure 1, were not always clearly explained or evident.
Based on the analysis of the literature to date, this author must agree with
the key findings reported by Romios, Newby, Wohlers, Spink, Gleeson, &
Goldstein (2003) when they conducted the study Turning wrongs into rights
project learning from consumer reported incidents. They reported that ―there is
Chapter 2: Literature Review
48
very little literature that reflects that complaints practice has started to
systematically and effectively inform service improvement processes‖(p. 2). A
key consideration is that there appears to be a lack of accountability by
organisations and services to not only report what is wrong in their systems, but
also to evaluate the effectiveness of initiatives implemented. Without this
evidence we will never know conclusively the full impact of these actions.
2.5.3. Identification of Organisational Impacts
The study conducted by Douglas and Harrison (1996) examining the effects
of a newly-implemented complaints handling process in a regional Australian
hospital, also addressed similar questions to those posed by this author at the
beginning of this literature review. They quote Rice (1986) who claims that
hospitals in Australia have a dismal record for responding to complaints about their
own standard of care; they responded by asking the question ―has anything changed
in the intervening years?‖ (p.126). It seems to be a commonly asked question that is
not being adequately answered. Perhaps Davidow‘s (2003) findings can be used to
explain why so many people still struggle to answer this question.
After reviewing sixty international empirical studies regarding the
positive and negative elements in the way organisations respond to complaints,
he concluded that managers apparently do not know how to formulate or apply a
response to certain situations. Despite the work that has been done in this area,
no framework exists that can be used by organisations in the measurement and
management of complaint response (Davidow, 2003). Without an existing
Chapter 2: Literature Review
49
framework or an underlying theory, we can never truly evaluate the
effectiveness of any potential paradigm related to complaints handling. These
findings are perplexing as an existing framework (EQuiP accreditation program)
existed in Australia when those findings were being discussed; yet, it would
appear that despite having a framework it had not begun to influence change.
Douglas and Harrison (1996) presented further contributions to
understanding organisational impacts and ineffective complaints handling. They
reported that staff viewed complaints handling processes negatively and that the
complaints evaluation process was sometimes viewed as a ―local witch hunt for
a suitable scapegoat‖ (p. 2). Based on this author‘s current experience in
complaints management this is still the case today. Staff perceptions, together
with an understanding of the complaints handling processes are among the many
challenges involved in improving mechanisms for patients to voice their
complaints (Gal & Doron, 2007).
It is unsettling to report that from analysis of participants‘ responses,
ineffective communication was identified as the most prominent thematic cluster
of issues. Ineffective communication was also identified by Douglas and
Harrison (1996) as being the catalyst for the majority of patient complaints
reported on in 1996. They stated that ―a lack of effective communication seemed
to be the most common underlying problem‖ (p. 3) associated with the
complainants‘ issues. While the management of complaints has been clearly
Chapter 2: Literature Review
50
identified as a significant organisational process, the reality is that it is still not
being managed effectively.
Ang and Buttle (2006) also postulated this assumption and attributed it
directly to minimal research being conducted to date to demonstrate and support
the types of processes conducted and sustained within an organisational
structure that are directly linked to outcomes such as customer satisfaction.
Davidow (2003) supported by Doig (2004) argues that the understanding of
organisational effectiveness in complaints handling has not developed, despite
the abundance of interest in this area, mainly because the studies to date are not
grounded; this failing represents a complaints paradigm that is representative of,
and can be applied to, health services. Until this theoretical understanding has
been developed and applied, limitations and uncertainties about conclusions
proposed in this area will always exist.
2.5.4. Examination of the Experience of Complainants’ and Influences of
Satisfaction
Doig (2004) considers the framework for understanding consumer
expectations and he draws on information developed through other service areas
regarding understanding complaints behaviour. The effects of dissatisfaction
through theories (such as attribution theory) have been used successfully to
understand the repercussions when a consumer is faced with a perceived service
failure. Rather than evaluating complaints solely from a process and systems
base, Doig (2004) argues that if we were able to understand why the person
Chapter 2: Literature Review
51
complained in the first place, through understanding their expectations, it would
assist us in the way we managed complaints, particularly at the first contact
stage when the complaint response has been triggered.
The study conducted by Daniel, Burn and Horarik (1999) regarding
patient complaints about medical practices examined the process from the
patient‘s perspective. The study explored what occurred before, during, and after
the patient had submitted a complaint to the New South Wales Health Care
Complaints Commission (HCCC). The study period was 18 months, and the
initial target sample of actual complaints lodged with the HCCC via a random
distribution sampling process was 500. The final participation rate and findings
were presented representing 63% of the original sample size. While the study
discussed their outcome measures and why this area was being investigated, the
opportunity to test any hypothesis regarding their purported assumptions was not
presented. Their primary interest was to develop a profile of the complainants
and the doctor involved in the incident that generated the complaint, and to
identify key events that occurred during the complaints handling process. An
assumption must be made that the authors of the study developed the tool used,
which was a 32-item questionnaire. There was evidence that the tool was trialed
and revised but, as has been shown in other studies, its validity was not
presented. The tool used in this study was not attached, nor was there any
reference to the actual questions used. A summary of the key themes of the
questionnaire was all that was provided.
Chapter 2: Literature Review
52
The conclusion reached by this study indicated that consumers knew
their rights and the avenues they could take to access these sources. However,
this generalisation could be viewed as being biased and not representative of the
target population. This view is supported by the fact that the group surveyed had
already used the service, so the question of whether they would access the
service could be seen as being superfluous in terms of their knowledge regarding
their rights. It may have been more appropriate to have them detail what other
avenues they took or who informed them about this process of complaints
handling. Overall, the survey findings concluded that the respondents were not
fully satisfied with the outcome they achieved. Once again, it could be
concluded that these findings are biased because the expectations of the group
surveyed may be disproportionate to the general target population. The findings
indicated that the survey respondents were of a higher occupational status and
better educated than the typical population; therefore, it would not be unusual to
see that the findings reflected that this group had greater expectations.
The importance of consumer participation regarding potential positive
contribution can best be understood, particularly from an Australian perspective,
from Draper‘s (1997) Lessons from Australian Hospitals study. One of the case
studies presented highlighted the usefulness of treating complaints as a positive
way of receiving feedback from health consumers to guide changes and
improvements. Further in the study, Draper (1997) synthesises a variety of
sources and explains the relevance of each and how they can individually and
Chapter 2: Literature Review
53
collectively be used to measure and evaluate satisfaction or dissatisfaction.
These mechanisms and tools included surveys, focus groups, interviews,
observation, critical incident analysis, literature reviews, and the systematic
analysis of complaints and associated data. From the reviews presented in this
paper, this last mechanism has been the most consistently used, particularly in
Australia to date.
The analysis of complaints data can provide excellent insights into
consumer views about organisational quality and, over the years, studies have
been undertaken to do just that (Draper & Hill, 1995; Wal & Lens, 1995; Wiele,
Boselie, & Hesselink, 2002; Zairi, 2000). In spite of this, the analyses of many
of these studies have cited varying degrees of limitations and gaps in their
findings, particularly in relation to the data comparability.
2.6. CONCEPT MAP OF COMPLAINTS RESOURCES
To establish the scope of the literature review it was important to be able
to identify what mechanisms were in place, what sort of research has been
conducted, and what issues have occurred. Figure 2, entitled Concept Map for
Complaints Research in Queensland, Australia, illustrates how this author began
investigating what sources were available in terms of complaints management.
The most obvious commonality in the opinion of this author that was
identified by constructing this concept map was the number of complaints
resources that were in place at the time of exploring these sources in April of
2006. Perhaps the preoccupation with implementing reactive policies and
Chapter 2: Literature Review
54
procedures over the last two decades, which is evidenced in the number of
resources developed not only in Queensland but also throughout Australia to
manage complaints, has limited the scope of our understanding and thwarted
positive long-term outcomes and organisational cultural shifts in this area.
Figure 2: Concept Map for Complaints Research in Queensland, Australia
2.7. SUMMARY OF AUSTRALIAN HEALTH REFORMS
April 20, 2010 was another important date in the history of Australian
health reform. This was the critical date when the Commonwealth Government was
given the green light by the state governments (excluding the Western Australian
Chapter 2: Literature Review
55
Government) to begin the overhaul of the current health system. However, what
reforms have occurred to date? Is it possible to identify a chronology of events
illustrating what has necessitated this radical shift in the control of the existing
health care system? The answer is yes, but it is quite disturbing that the literature
over the last twenty years primarily reveals significant scathing evidence as to the
inadequacies of the existing health care system. Within this litany of negativity there
has been some evidence of initiatives that have been successful in driving health
reform which also warrants recognition. To remain within the scope of the theme of
this thesis, health care reforms detailing complaints handling only will be presented.
It would be reasonable to state that the majority of health care services
throughout Australia would have some type of complaints handling process as part
of their operational systems. These systems would vary from being a compulsory
system linked directly to a variety of accreditation standards so as to receive
funding, or in some instances are operating voluntarily. Up to July, 2010, as well as
the local management of complaints by individual services, each state and territory
of Australia also has independent bodies that have been responsible for the bigger
picture of complaints handling (Jones, Meehan-Andrews, Smith, Humphreys,
Griffin, &Wilson, 2006).
Fletcher (2000) suggests that there have been a number of influences and
factors that have driven the focus on quality that has highlighted inadequacies from
the Australian context of health care. It is this focus, and at times intense media
scrutiny, that has led to changes and reform. One cannot emphasis enough the
Chapter 2: Literature Review
56
influence that the study conducted from 1992-1995 (the Quality in Australian
Health Care study) had on understanding the potential ramifications when
unexplained variations to patient care occurs. Following this report, significant
reforms began to be implemented towards achieving improved safety and quality
outcomes for patients. Unfortunately, due to the complex nature of the existing
health care system throughout Australia, an integrated approach, whether at state or
national level, has been challenging (Fletcher, 2000; Podger & Hagan, 1999).
Following the release of QAHCS in 1995, a taskforce was established to
investigate the findings that were reported. The year after the taskforce had
reviewed all facets of the QAHCS report, they made several recommendations. The
most significant was the implementation, in 1997, of a National Expert Advisory
Group on Safety and Quality in Australian Health Care. The aim of their manifesto
was to continue to add value to the work already completed by the Taskforce. The
chief objective was to provide health ministers in Australia with expert advice about
safety and quality in Australian health care (Final Report to Health Ministers from
the National Expert Advisory Group on Safety and Quality in Australian Health
Care, July, 1999).
Towards the end of the 1980s and the beginning of the1990s, many states
in Australia had either undertaken reforms or were beginning the reform process
into regulations surrounding the practice of health care by doctors and nurses. For
example, in the 1990s, Victoria passed ten Acts of Parliament to facilitate the ability
of registration boards to deal with issues such as complaints being made against
Chapter 2: Literature Review
57
individual practitioners. A variety of studies has been conducted to evaluate the
success of various boards throughout Australia. In Victoria in 2002 complainants
who had lodged a complaint about health care workers expressed their concerns and
doubts about the effectiveness of boards to ―police‖ their own. Issues surrounding
transparency, accountability, and impartiality were regularly being raised (Romios,
et al. 2003). While the Victorian Department of Health recognised the importance of
such findings and pledged significant principles to be implemented to improve
consumer confidence in the complaints handling system, today there are still
significant shortfalls that are evident in the health care system. Over the course of
preparing this literature review there has been a significant amount of work
accomplished at both a State and National level throughout Australia in regards to
health reform. While recent reforms presented in 2010 reflect very positive
frameworks to potentially influence change in health care service improvement,
these reforms are still in the process of being implemented. The following
information introduces the national policy reforms that are currently in place and are
being implemented, which have the potential to influence complaints handling in
the future. These reforms will be highlighted further in Chapter 6 to support and
guide the recommendations through this new lens of change.
2.7.1. Australian Charter of Healthcare Rights
In 2008 a national charter of healthcare rights was presented as a strategy for
health settings to adopt, with the view to promoting and committing to patient-
centred care. The Rights of the Charter are: ―safety; respect; communication;
participation; privacy; and comment‖ (Health Consumers Queensland….your voice
Chapter 2: Literature Review
58
in health, 2010, p. 2). A discussion paper released in September 2010 by the
Australian Commission on Safety and Quality in Health Care, proposes that the
Charter of Healthcare Rights has the foundational principles for enhancing
opportunities to achieve patient-centred care.
2.7.2. National Health and Hospitals Network Agreement (NHHN)
The NHHN has been proclaimed as the ―most far-reaching structural
reforms to the health system since the introduction of Medicare‖ (A National
Health and Hospitals Network for Australia’s Future—Delivering better health
and better hospitals. 2010, p. 2). This Agreement was reached at a meeting held
by the Council of Australian Governments, in April of 2010.
This Agreement outlines the accountability and performance measures
that will be directly linked to the funding of Australian public hospitals
(excluding Western Australia)2. These national standards will be able to provide,
for the first time in Australian health care, comparable data relating to the
performance of public hospitals. Incorporated within this agreement are several
reforms which are either in the process of being implemented or will be in the
near future. This network ―provides the national framework for a suite of
changes that are designed to provide a sustainable foundation for providing
better health services now and in the future. The NHHN outlines reforms in five
key areas:
2 As of 13
th February 2011, COAG published a communiqué updating the previous agreement of
April 2010, to reflect a unanimous State and Territory agreement to adopt the same health
reforms.
Chapter 2: Literature Review
59
1. Public hospitals and local hospital networks (LHN);
2. Primary health care and primary health care organisations;
3. System financing;
4. Performance and accountability; and
5. National governance, (A Local Hospital Network for the Australian
Capital Territory, 2010, p. 4).
With the advent of these reforms a number of new entities are to be
established to ensure effective governance related to health care delivery in
Australia. Whilst these entities are still to be made fully functional, an opportunity
exists to link these entities with the recommendations of this study.
2.8. SUMMARY
The literature presented thus far has ideally provided insight into the
types of studies that have been conducted, particularly from an Australian
perspective, related to complaints handling. Health reforms that have influenced
the development of many complaints handling processes have also been
introduced. The factors that actually influence complaint behaviour are an
important aspect in understanding what motivates people to complain in the first
instance.
However, before we try to understand why people complain, we must
consider whether there are resources and mechanisms in place to be able to
capture and respond to these issues. One of the guiding questions of the
literature review was to identify what resources have been developed to manage
Chapter 2: Literature Review
60
health care complaints in Queensland. This focus uncovered a plethora of
complaints resources, yet positive long-term outcomes and organisational
cultural shifts were less obvious in the literature as a result of these policies and
processes. It is clear that while the handling of complaints has been identified as
a significant organisational process, the reality is that it is still not being
managed effectively. From this study and the literature reviewed, the clear
message being expressed is that there is a changing landscape of complaints
culture, and that complaint handling should not be managed by a specific
department or an individual, but that the responsibility must be assumed by the
organisation as a whole.
Chapter 3: Methodology, Design and Methods
61
Chapter 3: Methodology, Design and Methods
3. INTRODUCTION
The previous two chapters have discussed the relevance of, and presented
supporting literature to confirm, the rationale of this study. This chapter presents and
discusses the methodology, design, and methods used to undertake this study. It
addresses two important questions: What can we learn from patients who have
experienced the complaint process in a Queensland hospital? And how will this
information assist health services to develop service improvements with regard to
complaints handling?
The research design of this study is qualitative in nature; essentially,
qualitative researchers focus on the interpretation of a human phenomenon (Denzin
& Lincoln 2005; Heath, 1997). The methodological exploration is explained further
―I personally believe we developed language because of our deep
inner need to complain‖ (Jane Wagner (1935- )
Chapter 3: Methodology, Design and Methods
62
in this chapter, leading to the rationale for the research design used. The contextual
framework used to assist with the research question exploration is discussed.
Finally, the methods used including sampling strategy, instruments used, interview
guide, data analysis strategies, ethics, limitations, and thesis timeline are detailed in
this chapter.
3.1. METHODOLOGY
3.1.1. Study Design
This study is guided by a phenomenological perspective representing an
interpretative approach from a Heideggerian perspective. The importance of the
methodology cannot be understated. The recurrent theme evident in literature on
research design is that methodological rigour is the foundation of valid research.
Fahie (1994) quotes Jick (1979) who stated that ―if the research is not clearly
focused theoretically and conceptually, all methods in the world will fail to
produce a satisfactory outcome‖ (p.141). Within the field of qualitative research
there are several methodological frameworks that could have been used to
explore the phenomenon of complaining. Based on the primary objective of this
study, which is to explore the meaning of the experience of patients engaging in
the complaint process to determine what health services can learn from them, the
philosophy of phenomenology is the most appropriate design to interpret this
question (Denzin & Lincoln, 2005; Johnson & Silburn, 2000; Warren & Karner,
2005).
Chapter 3: Methodology, Design and Methods
63
An initial exploration of the research focus from a purely
phenomenological standpoint (based on the Husserlian perspective) reflects a
research paradigm which according to Lester (1999), ―seeks essentially to
describe rather than explain, and to start from a perspective free from
hypotheses or preconceptions‖ (p. 1). The fundamental concept of this research
methodology is the avoidance of the researcher‘s own preconceptions
impacting on the study. Essentially, by undertaking a literature review in the
area of interest surrounding complaints handling, one could already have
potentially compromised undertaking this study from a Husserlian
phenomenological perspective (Koch, 1995; Giorgi, 2005). However, if we
draw on the work of Heidegger, whereby his philosophical framework accepts
and acknowledges that the data that findings from the research has, by its very
nature, a connection between the participant and the researcher (Dealey, 2003;
Wojnar & Swanson, 2007), undertaking a literature review will not diminish or
contaminate the findings. Cohen and Steeves (2000) confirm that, within the
context of Heidegger‘s perspective - as opposed to the Husserlian branch of
phenomenology - the literature review is acceptable. The Heideggerian
perspective also demonstrates the suitability of using this methodology in the
context of how the research question was posed in the first instance. Dealey
(2003), in the study she conducted on the lived experience of patients with
pressure ulcers, states that a research question should arise, or be drawn, from
a personal or professional question, as presented in Chapter 1.
Chapter 3: Methodology, Design and Methods
64
In brief, the framework of phenomenology owes its construction to
many individual philosophers including Husserl, Heidegger, and Merleau-
Ponty (Lindseth & Norberg, 2004). Of most interest for this study is the
hermeneutic approach, also known as interpretive phenomenology, postulated
by Heidegger (Laverty, 2003). This approach suggests that as individuals we
are most likely to be able reflect on our own lives to identify specific meaning
and the significance of certain events. To be able to enter into the world of
others via the hermeneutic inquiry, a shared understanding must occur between
the researcher and the participants to facilitate and identify the meaning of the
data that is being collected about the phenomenon (Smith & Osborn, 2003;
Wojnar & Swanson, 2007).
While examining the historical phenomenological contributions and
developments in terms of methodology, it was apparent that phenomenology
has had a significant influence on many disciplines across many nations.
Phenomenology, as a research methodology, is complex. This
complexity offers one the opportunity to undertake and explore a variety of
reflections maintaining distinct phenomenological insight. So, the challenge in
undertaking this exploration is to maintain integrity and rigour in our
examination of the phenomenological world.
Experts at a phenomenological conference held in Molde, Norway
(2009), were all asked whether we, as researchers, should be focusing on the
differences within phenomenology in the context of the different disciplines, or
Chapter 3: Methodology, Design and Methods
65
concentrating on the commonalities to ensure rigour. Amadeo Giorgi stated,
very succinctly, ―use phenomenological inspired language‖. Dan Zahavi added
―can others confirm what your findings are showing‖? Both Patricia Benner
and Gunn Engelsrud supported the premise that the phenomenological inquiry
being undertaken must be intrinsically linked with the world of the
phenomenon being explored (Benner, Engelsrud, Giorgi, & Zahavi, personal
communication, June 20, 2009). In other words what is the relevance of
undertaking a phenomenological exploration from a nurse‘s perspective, a
dancer‘s perspective, or even a philosopher‘s perspective? The connection and
the relevance must be implicitly evident. This relevance can be identified in the
personal reflections offered by the Author in Chapter 1.
The common theme among many of the phenomenological philosophers
was that, as stated by Ploeg (1999) ―the source of data is the life world of the
individual being studied‖ (p. 36). This is usually where novice researchers start,
but from this point, the acquisition of phenomenological knowledge will vary.
For ease of description the domains of phenomenological inquiry have
been used to consolidate the phenomenological world into a realm of
understanding.
3.1.2. Domains of Phenomenological Inquiry
The information provided in Figure 3 is an adaptation of the illustration
entitled ―The Domains of Inquiry‖ by Max van Manen (2002), in which he
depicts the domains that he discusses when undertaking a phenomenological
Chapter 3: Methodology, Design and Methods
66
inquiry. For a novice researcher, it provides direction to stay focused on the
methodology while undertaking the phenomenological exploration. It is
interesting to note that many books about undertaking research do not fully
explain phenomenology in detail, or that the detail is so deep and convoluted
that it is hard to understand. O‘Leary (2004) makes this same observation, and
states that ―the literature on the topic is thick and hard to read: is theoretically
and conceptually divergent; and does not offer much clear guidance when it
comes to actual ‗methods‘‖ (p 123).
One of the greatest hurdles for novice researchers undertaking a
phenomenological exploration is not to misinterpret the language. Taking a
gradual approach through the domains of Methodology, Orientations in
Phenomenology, Methods and Procedures, Writing, Sources of Meaning and the
Epistemology of Practice has enabled this author to stay focused on the
phenomenological inquiry process. The perspectives that were used within this
inquiry process are identified in Figure 3 by the red text. These perspectives will
be presented to illustrate the processes undertaken in this inquiry to examine the
lifeworld of a patient making a complaint.
Chapter 3: Methodology, Design and Methods
67
Figure 3: Domains of Phenomenological Inquiry
Source: Adapted from: Phenomenological Inquiry (2002) Max van Manen http://www.phenomenologyonline.com/inquiry/1.html
Epistemology of
Practice
Methodology
Phenomenological
Inquiry EMPIRICAL METHODS Orientations in
Phenomenology
Writing
Sources of
Meaning
REDUCTION
DIMENSION
Heuristic Reduction
Hermeneutic Reduction
Phenomenological Reduction
Eidetic Reduction
Methodological Reduction
Ontological Reduction
Vocative Turn
Revocative Turn
Evocative Turn
Invocative Turn
Convocative Turn
Provocative Turn
VOCATIVE
DIMENSION
Hermeneutic Interview
Reflection
Exegetical Reflection
Linguistic Reflection Collaborative Reflection
Guided Existential Reflection
Thematic Reflection
REFLECTIVE METHODS
Seeking Entering
Traversing
Drawing
Gazing
Touching
Transcendental
Existential
Hermeneutical Linguistical
Ethical
Experiential
Describing
Gathering
Interviewing Observing
Fictional
Imaginal
Experiential
Language
Social Science Phenomenological
Historical
Literary/Aesthetic
Embodied
Actional
Situational Relational
Perceptiveness
Interpretive Sensibility
Pathic Intuitiveness
Situational Confidence
Thoughtful Action
PRACTICE as TACT
Methods
& Procedures
PRACTICE as PATHIC
KNOWLEDGE
Do
ma
ins o
f Ph
eno
men
olo
gica
l Inq
uiry
Chapter 3: Methodology, Design and Methods
68
3.1.3. Orientations in Phenomenology
The orientations that can be undertaken within a phenomenological
exploration reflect a variety of different viewpoints that have arisen through
various philosophical underpinnings (Van Manen, 1997). The traditional aspect
of this study is steeped in hermeneutic orientations. The phenomenological
movement of hermeneutics has close associations with the philosophical point of
view of Heidegger, Gadamer, and Ricouer (Cohen & Omery; Ray; Koch;
Draucker; Streubert & Carpenter; Lopez & Willis as cited in De Witt & Ploeg,
2006). Essentially, Heidegger and his followers sought to discover the all-
encompassing question of the meaning of being. This road of discovery elicited
many concepts that are used as part of phenomenological language. For
Heideggerian phenomenologists the central core is the concept of being and the
term coined by Heidegger in 1962, known as dasein, which is a German word
meaning existence. It is this ontology of one being in the world that is the
scaffold of Heidegger‘s hermeneutic approach (Plager, 1994; Van Manen, 1997;
Wojnar & Swanson, 2007). Simply put, in terms of this study it means ‗being
there‘, and it is a way to understand the experience of individuals who have
become conscious of something that occurred in their lifeworld (Annells, 1996;
Dreyfus, 1999).
3.1.4. Writing
The key objective of any phenomenological writing is to uncover, or
discover, the true meaning of the phenomenon being explored (Dowling, 2004,
Chapter 3: Methodology, Design and Methods
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Van Manen, 1997). However, Van Manen (2002) asks, how possible is it to
know when all meaning has been truly explicated and interpreted. Is it more
realistic to acknowledge and understand, right from the outset, that no text will
ever be truly perfect? Therefore, the challenge then becomes evident - one must
be vigilant, diligent and committed to the art of writing, and examine and
explore with a sense of purpose.
There are key elements within the writing process that were used while
undertaking this study. Firstly, the writing process generated a variety of
reactions and emotions for this author. At times the writing process became
absorbing, and isolating. At other times it became very frustrating, with the
phenomenon being explored, not with the narratives. When experiencing such
complex emotions, it is hard to sustain intensity for long periods. Undertaking
the transcription of the interviews was by far the most challenging aspect of the
writing process. The transcription was not an easy process, primarily because the
phenomenon being explored dealt predominately with negative experiences.
However, one could propose that the insights gained from the
interpretation of the text may have not been achieved without enduring the
difficulties presented by the writing process. A key component of the writing
process was the immersion within the hermeneutic circle. The hermeneutic
circle essentially represents the relationship between the observer and the
participant and understanding the dialogue in the context of the phenomenon
being explored. The process is not linear: it is in fact, and must exist within, a
Chapter 3: Methodology, Design and Methods
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constant motion of construction and deconstruction to achieve a shared
understanding of the phenomenon being explored (McConnell-Henry, Chapman,
& Francis, 2009; Polkinghorne, 1983).
... In other words, the participant offers their story, and by looking and re-
looking at the data, searching beneath the words and at what is not immediately
obvious, the researcher aims to end up with an ontological perspective of the
participant‘s experiences. By utilizing the hermeneutic circle the researcher
attempts to ‗read between the lines‘ and uncover the true essence of the
experience (McConnell-Henry, Chapman, & Francis, 2009, p. 11).
3.1.5. Methodological Impulses
Van Manen (2002) proposes that within the phenomenological inquiry and
the process of undertaking the inquiry, distinct methodological impulses exist to
guide the writing process. These impulses may take either a reductive or vocative
dimension. The path of reductio takes on the form of establishing the epoché.
Epoché means to suspend any preconceived assumptions or judgements one may
have about a belief, and as such bracket these assumptions to explore a phenomenon
from its purest form to identify its essence. This concept was introduced at the
beginning of this chapter to explain the Husserlian approach to undertaking a
phenomenological inquiry. It bears further comment here, with regard to the variety
of specific terminology that exists as a consequence of which specific
methodological impulse has been undertaken in a study. Clearly, from what has
been presented so far, this study is not a representation of a reductive approach but
one of a vocative dimension.
Chapter 3: Methodology, Design and Methods
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3.1.6. Sources of Meanings
It is well accepted, within phenomenological inquiry, that the language
used while talking about an experience has the opportunity to provide insights
and understanding into other aspects of the experience which can only be
identified by the interpretation of the language that may not be as conspicuous.
This can only be undertaken by drawing on a variety of information that is used
to establish the sources of meaning. Two particular sources were used to explore
the interview data of this study, in order to establish the essence of the narrative.
Firstly, in examining language it is evident that the text can have alternative
meanings, for example, the use of sarcasm, self-deprecating descriptors, humour
to hide anger, and metaphors were all evident throughout many of the stories
collected. These insights have been used to focus on and explore the narratives.
Secondly, as the origins of the phenomenon being explored are deeply rooted in
the social sciences it is only appropriate to explore the meanings of the text by
examining current social science theories that reflect the coping behaviours of
individuals experiencing different emotions.
3.1.7. Contextual Framework
As part of the interpretative endeavour of this study, Lazarus’ cognitive-
emotive model of coping with situational challenge has been drawn on to
provide a contextual understanding of the emotions discussed by the study
participants.
Chapter 3: Methodology, Design and Methods
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Cognitive appraisal theory can be best understood by the following
simplified schematic representation.
Figure 4: Simplified Cognitive Appraisal Theory
Figure 4 is based on the descriptors examined by Lazarus (1993),
Stephens and Gwinner (1998), and Watson and Spence (2007). They all
identified that when an individual experiences an event, it then usually becomes
the catalyst for the individual to think about how this event will affect them. The
individual then determines or appraises how they perceive they will respond or
cope with that given event or situation. The final step of this process will
determine how that individual will behave or respond. This outcome is
dependent on what emotions the individual has experienced as a consequence of
that specific event or situation.
While this process is described as a series of well-defined steps, the
actual process is much more fluid than the step by step depiction in Figure 4.
Situation/
Event
Primary
Appraisal We think about the
situation/event and how
it will affect us
Secondary
Appraisal We determine how we will
cope or respond to the
situation/event
Appraisal
Outcome Emotion
Coping Strategy
Chapter 3: Methodology, Design and Methods
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Essentially, Lazarus‘ cognitive appraisal theory reflects the ways human
beings cope with life challenges and stresses. The use of cognitive appraisal has
been used predominately in service areas, such as in the tourism and hospitality
sectors. Primarily the use of this appraisal theory in these service areas has been
from a marketing perspective to evaluate the impact that emotions have on post
purchase behaviours (Bagozzi, Gopinath, & Nyer, 1999; Chebat, Davidow, &
Codjovi, 2005; Watson & Spence, 2007; Nyer 2000). However, there has been
minimal research to date using this contextual approach to explore the emotions
of patients who have experienced a negative situation and then made a conscious
decision to either complain or not.
Cognitive appraisal is a key part of the emotional experience, and
studies to date reveal that anger is a main driver of complaining behaviour, while
the experience of resignation is the main driver of non-complaining behaviour
(Lazarus, 1991; Stephens & Gwinner, 1998; Watson & Spence, 2007). An
understanding of the emotions that drive patient complaint behaviour may
provide invaluable insights into early predicators of feelings of dissatisfaction.
This emotional understanding leads well into asking the question about the
levels of anger patients may experience and whether the emotion of anger, as is
seen in other service areas, provides us with any early predictors of
dissatisfaction. The following questions will be explored.
Chapter 3: Methodology, Design and Methods
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3.1.7.1. Q1: The Emotion of Anger
Is the emotion of anger always experienced by patients preceding a complaint
being made?
While we can draw on the work available from other industries, there are
some distinct differences that will need to be examined to truly understand this
phenomenon from a hospital patient‘s perspective. Emotions can be experienced
and portrayed differently, depending on the context in which that emotion has
been experienced (Lazarus, 1991; Schoefer & Ennew, 2005; Vinagre & Neves,
2008). Being a patient in a hospital would not have the same
―customer/consumer‖ implications as someone having a bad dining experience,
for example. So, while a diner who is unhappy with his meal (primary
appraisal), could become angry and then make a conscious decision to send his
meal back (secondary appraisal) to demonstrate that he is unhappy with the
service, would a patient have the same recourse? This insight warrants further
examination and the following question will be explored in the narratives of the
participants of this study.
3.1.7.2. Q2: Consumer/Customer Right to Complain
Do patients consider that they have the same consumer/customer right to
complain as in other consumer/customer settings and do they know how to
complain?
Another important aspect of the cognitive appraisal process in line with
the way we can react, suggests that as individuals we tend to respond only to an
Chapter 3: Methodology, Design and Methods
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event or situation in which we think that we have some capacity to control the
outcome. If through the appraisal process we deem the situation to be totally out
of our control, with minimal opportunity to influence the situation, the end result
is usually denial or complete resignation to the situation (Peacock &Wong,
1990; Schoefer & Ennew, 2005). Responses such as denial or complete
resignation according to Folkman, Lazarus, Dunkel-Schetter, DeLongis, &
Gruen (1986) are attributed to the coping mechanisms we have learnt to use. The
definition of coping provided by Folkman et al. (1986), describes the ―person's
constantly changing cognitive and behavioural efforts to manage specific
external and/or internal demands that are appraised as taxing or exceeding the
person's resource‖ (p. 993).
3.1.7.3. Q3: Motivation to Complain
Do patients who complain consider that they have an opportunity to improve
the situation that they are complaining about, or what is their motivation to
complain?
Research into service delivery failures has identified that if a service
provider responds appropriately to a consumer who has expressed some negative
emotions about the service interaction, they are more likely to develop a better
relationship with that customer and thus retain them as a customer (Bodey &
Grace, 2006; Schoefer & Ennew, 2005).
Chapter 3: Methodology, Design and Methods
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3.1.7.4. Q4: Influences on Future Hospital Admissions
Do patients develop better relationships with service providers who respond
appropriately to their complaint, and how does this relationship influence future
hospital admissions?
So, while presenting the role our emotions and coping capabilities could
play in the context of understanding the complaint handling situation within the
environmental context of the patient and the hospital setting, one must concede
that it is not a clear-cut approach. While the cognitive appraisal process can
assist with the process of exploring the narratives of the participants to elicit a
thematic understanding, a model to conceptualise how emotions will be
measured also needs to be considered. In terms of this study, the most
appropriate measure of emotions that can assist the hermeneutic process will be
drawn from Lazarus‘ (1993) presentation of fifteen emotions and their
associated core relational themes. This measure will be discussed later in this
chapter.
3.2. METHODS AND PROCEDURES
3.2.1. In-depth Interviews
It has been discussed by phenomenologists, such as Van Manen (2002),
that to undertake a phenomenological exploration requires the researcher to use
two methods of inquiry: firstly, an empirical approach and secondly, a reflective
approach. Another point to consider when undertaking a phenomenological
approach is that, while using words such as empirical and reflective, one should
Chapter 3: Methodology, Design and Methods
77
not presuppose that there is a magical formula or a set of prescriptive steps one
must follow. However, it is also important to heed the advice of Giorgi (1997) as
cited in Findlay (2009) who presents the tenet that as ―a human science,
phenomenology aims to be systematic, methodical, general, and critical‖ (p. 14).
Within the study being presented the empirical method chosen was the
interviewing experience. Within the context of Heideggerian hermeneutic
phenomenology, one of the most appropriate methods for study use is the semi-
structured interview, also referred to as an in-depth interview approach. With
this type of interview approach there is no prescriptive set of questions; it
should proceed more like a free-flowing, spontaneous conversation (Denzin &
Lincoln, 2005). However, a general guide to the types of questions that need to
be explored as part of the phenomenon has been developed to provide
participants with insight into the study objectives. The value of this type of
approach is that the interview has the potential to go in a variety of directions.
The fundamental issue is the information gathering and recording of the
participant‘s beliefs and values. Using this approach the author did not use
leading questions, nor probe beyond an expected answer; but took the
opportunity to explore inconsistencies when, and if they presented and,
importantly, captured exactly what was said (Denzin & Lincoln, 20005; Smith ,
1995).
This may raise some discussion as to whether the use of an interview
guide, which was given to the participants in the information package, has in
Chapter 3: Methodology, Design and Methods
78
some way influenced or provided leading, and thus biased the participant‘s
responses. One must be very clear about the question and the phenomenon
being explored; and, it is important to know how to contextualise it to make
sense of your study objectives when you describe them to others. So, the purpose
of providing the participants with the interview guide was to contextualise the
phenomenon for them. The guide was not used as a prescriptive
question/response prompt; it was provided as the background and formed the
glue that bound together the topics of interest. The interviews would generally
start with a question relating to why the participant complained about their
hospital care. Questions were then asked in the context of the established
boundaries but in spontaneous response to the narrative being provided.
The next part of the process, once the interviews were completed, was to
make sense of all of the words. This is where the reflection process aids in the
exploration of the phenomenon. The difficulty with this process is how to assign
meaning so that we truly understand the lived meaning of the words being
presented by the individual. The reflective method undertaken has been taken
from the linguistic reflection exploring the contextual nature of the meanings of
the words. Examples of the outcome of this type of reflection are shown in
Chapter 4 when discussing the sources of meaning of the narrative being
interpreted.
The contextual framework supporting the thematic analysis of the
interview data has been drawn from Lazarus‘ Cognitive Emotive Model of
Chapter 3: Methodology, Design and Methods
79
Coping. Lazarus‘ cognitive appraisal theory reflects the ways in which human
beings cope with life challenges and stress as presented earlier in this chapter.
The model of emotions and the core relational themes that have been used to
assist in the thematic analysis of the narrative are presented in Table 5.
3.2.2. Model of Emotions and Core Relational Themes
Table 5: Emotions Table
Emotion Core Relational Theme
1 Anger A demeaning offence against me and mine
2 Anxiety Facing uncertain, existential threat
3 Fright An immediate, concrete, and overwhelming physical
danger
4 Guilt Having transgressed a moral imperative
5 Shame Failing to live up to an ego-ideal
6 Sadness Having experienced an irrevocable loss
7 Envy Wanting what someone else has
8 Jealousy Resenting a third party for the loss of, or a threat to,
another‘s affection or favor
9 Disgust Taking in or being too close to an indigestible object or
idea (metaphorically speaking)
10 Happiness Making reasonable progress toward the realisation of a
goal
11 Pride
Enhancement of one‘s ego-identity by taking credit for a
valued object or achievement, either one‘s own or that of a
person or group with whom one identifies
12 Relief A distressing goal-incongruent condition that has changed
for the better or gone away
13 Hope Fearing the worst but wanting better
14 Love Desiring or participating in affection, usually but not
necessarily reciprocated
15 Compassion Being moved by another‘s suffering and wanting to help
Emotions Table (source: Lazarus, 1993, p.13)
Chapter 3: Methodology, Design and Methods
80
An emotions checklist was assigned to each of the participants‘
narratives, reflecting the number of emotions identified throughout. An example
of a completed checklist has been included in Appendix F.
3.3. SAMPLE INFORMATION AND INSTRUMENTS
The recruitment strategy used for this study was a purposive sampling
strategy known as a judgement sample. This sampling process provided an
opportunity to enlist participants with very specific information about a subject
area of interest (Marshall, 1996). In addition to this purposive sampling strategy
specific criteria were used in order to facilitate the inclusion of participants with
direct knowledge about the experience of complaining. This approach according
to Morse and Field (1995) is driven by the underlying needs of the study and as
such will ensure that the data being collected is truly representative of the study
under investigation.
3.3.1. Recruitment Strategy
Appendix A: Recruitment Flow Chart illustrates the recruitment strategies
used in this study. A series of three steps described by MacDougall and Fudge
(2001) was used in preparing this strategy. MacDougall and Fudge (2001) proposed
this checklist approach after completing a synthesis of the literature investigating
sampling approaches for focus groups and in-depth interviews. They concluded that
this three-stage approach involving preparation, making contact, and providing
follow-up will assist in overcoming many of the recruitment issues that they
identified in the literature they reviewed.
Chapter 3: Methodology, Design and Methods
81
Table 6 provides a snapshot of the recruitment strategy followed for this
study. Following on from this table more detail is provided.
Table 6: Sampling and Recruitment Strategy Checklist
Sampling and Recruitment Strategy Checklist
Step 1: PREPARATION Activity & Location in Thesis (for more detail)
Sample Description Criterion sampling strategy
identified. (3.4.1)
Identifying Information
Sources
Concept map of complaints
resources. (2.7)
Figure 2
Identifying Contacts Supervisors confirmed & key
stakeholders identified. (3.3.1)
Identifying Existing or
Related Projects
Literature review completed – No
other projects with same target
group identified. Chapter 2
Alternative Samples to be
Considered if Needed
Alternative target group required
and identified.
Appendix: A
(3.4.2)
Step 2: MAKING CONTACT
First Contact Sample group identified,
preparation for ethical
considerations commenced.
Emails sent to health care
consumer groups.
Advertisement seeking
participants posted.
Webpage developed specifically
for study.
Television interview (Channel 7
News) inviting participants.
(3.4.1)
(3.5.1)
Appendix: B
(3.5.2)
Appendix: C
(3.6.2)
Involving Key Contacts Discussion with supervisors. Key
Contact identified from
Bundaberg patients support
group.
(3.6)
Chapter 3: Methodology, Design and Methods
82
Sampling and Recruitment Strategy Checklist
Negotiations Commenced Formal Ethics application
submitted and approval received
Recruitment letter sent to
potential participants.
Appendix: B
Appendix: D
Providing Confirmation Information packages sent to all
potential Participants. Consent
form and stamped addressed
envelopes provided.
Appendix: E
Establishing Involvement Consent form provided contact
details. All potential participants
contacted first by telephone,
arrangements made for interview.
Appendix: E
Step 3: PROVIDING FOLLOW-UP
Participant
Communication/Feedback
Webpage maintained to provide
ongoing information about the
study. (3.6)
Key Contacts
Communication/Feedback IBID IBID
Establishing/Maintaining
Links IBID IBID
Dissemination of Findings Research Activities—to discuss
study.
1 X state conference, 1 X
national conference, 3 X
international conferences and
Webpage
Appendix:
R, S, T, U, V
Action and Advocacy Discussions at Conferences,
Lectures to Nursing Students. IBID
(adapted: MacDougall and Fudge, 2001)
Chapter 3: Methodology, Design and Methods
83
3.4. STEP 1—PREPARATION
3.4.1. Sampling Criteria
The primary criteria for the sampling strategy was to include people who:
Had been an in-patient in a Queensland hospital or an advocate of a
person who had been an in-patient in a Queensland hospital.
Had made a complaint, either written or verbal, to any agency during
1997-2007 about some aspect of their hospital stay.
Were over the age of 18 years of age.
Would be willing to participate in a face to face interview unless a
significant reason could be established to warrant an alternative format-
disclosure of this deviation would be presented.
Understood the length of time to undertake the interview was not
prescriptive. All data would be analysed, as long as the participant was
able to relay their experience within the timeframe that suited them to tell
their story.
Agreed to sign a consent form, indicating that they understood the
information sent to them about the study and to confirm their willingness
to be part of this study.
3.4.2. Alternative Target Group Identification
The recruitment strategy initially proposed for this study was to draw
from members of identified health care consumer groups who had been
inpatients of specific peer grouping of hospitals. The peer grouping was detailed
Chapter 3: Methodology, Design and Methods
84
in the Queensland Health Statewide Patient Satisfaction Survey Report, released
in February 2006. The information provided in that report detailed, among other
things, the highest and lowest percentage of total satisfaction that healthcare
consumers had with their hospital stay by peer grouping. This information was
to be used as criteria for inclusion in this study.
It was initially proposed that the participants of this study would have
been inpatients in one of the hospitals identified from each of the highest and
lowest categories of total satisfaction identified according to peer grouping. A
representation of participants was to be sought from those health care consumers
that had been inpatients pre and post September 2005. This timeline was chosen
to provide a link with the Queensland Public Hospitals Commission of Inquiry
which commenced in September 2005.
This target group was expected to provide an opportunity to explore both
the positive and negative aspects associated with the healthcare consumer‘s
inpatient experience. It had the potential to provide some insight into different
experiences between city and rural healthcare consumers, and would have
revealed any differences in experiences that could be attributed to increased
consumer knowledge about complaints systems following the Queensland Public
Hospitals Commission of Inquiry.
To focus the recruitment strategy it was proposed to select patient and
health care consumer support groups. The four support groups initially selected
for this study had been identified as having representation across the eight
Chapter 3: Methodology, Design and Methods
85
principal hospital geographical areas, reporting the highest and lowest
satisfaction with their care. A further four support groups were identified as
alternative participants in the event that no representation was available from
any of the original four support groups. The alternative groups were selected
based on providing the widest representation across the geographical areas
identified by the hospitals in the peer grouping.
However, the phrase coined by Nobel Prize winner John Steinbeck in
1937, ―The best laid plans of mice and men oft go awry‖ may describe the
failure of this initial recruitment strategy. The eight consumer groups initially
identified were all sent emails that detailed the rationale of the study and
requested a discussion about participation. See Appendix D for a copy of the
initial introduction letter. Unfortunately, all of the groups that were approached
declined to participate. While the responses from the representatives of the
consumer groups indicated a high degree of support for the study per se, there
was a consistent theme as to why they were declining. The overriding message
was that the purpose of a consumer support group is to provide positive support.
Many of the representatives indicated that the study might focus too heavily on
negative issues, and fail to reflect the supportive ethos that they strove to project.
A flow chart was prepared at the beginning of the recruitment phase to ensure
that each stage could be easily confirmed. See Appendix A: Recruitment Flow
chart. As indicated on the flow chart, a ―no‖ response at the critical recruitment
phase required a ―Plan B‖ to be implemented.
Chapter 3: Methodology, Design and Methods
86
The proposed strategy for Plan B was to try to reach as many potential
participants using a purposive sampling strategy that met the inclusion criteria
(detailed in 3.4.2.)
3.5. STEP 2—MAKING CONTACT
3.5.1. Ethical Considerations
Approval for this study to proceed was granted by The Queensland
University of Technology (QUT) University Human Research Ethics
Committee, on July 18, 2007. This study was classed as a level two application
as it only involved participants who were able to give informed consent. The
approved Human Ethics Approval Certificate is available for viewing in
Appendix B. The study participants did not include any minors. The study was
open to all participants who met the inclusion criteria detailed earlier in this
chapter. Data and findings presented have not identified any of the participants.
No inducements or gratuities were offered to the participants. No aspect of this
proposed study involved deception or compromised the participants‘ privacy.
3.5.2. Establishing Confirmation
A newspaper recruitment advertisement (see Appendix C) ―seeking
volunteers‖ was placed in the following Newspapers: The Toowoomba
Chronicle, Northside Chronicle, Westside News, Southern Star, City News,
Caboolture Shire Herald, Ipswich News, Logan West Leader, South East
Advertiser, and South -West News. The advertisement ran over a four month
period. A webpage was also developed to provide potential participants and
Chapter 3: Methodology, Design and Methods
87
other interested parties with more information about the study. Potential
participants who wanted to request an information package were able to access
an automatic request via the webpage‘s email link. The following instrument
sheet (Table 7) was used to collect information about the participants; the
findings are presented in chapter 4.
Table 7: Participant Information Sheet
Complaints Study—Participant Information Sheet
What was the nature of your admission to hospital for this visit?
SURGICAL—you had surgery or an operation while you
were in hospital yes no
MEDICAL—you were admitted for an investigation,
procedure and/or treatment (including antenatal care), but you
did not have surgery or an operation
yes no
MATERNITY— you gave birth while in hospital yes no
Not sure yes no
Are you male or female? (Please circle) Male Female
Age group? Country of Birth?
18-24 years Australia
25-34 years U.K
35-49 years New Zealand
50-64 years Greece
65-79 years Italy
80 years or over Other—Please specify
Do you speak a language other than English at home?
Please specify:
yes no
For your stay in hospital, were you treated as a:
Public or Medicare patient yes no
Chapter 3: Methodology, Design and Methods
88
Complaints Study—Participant Information Sheet
Motor Vehicle Insurance (MVI) patient
Private patient Department of Veterans Affairs (DVA) patient yes no
Work Cover patient yes no
Other—please specify: yes no
Are you of Australian South Sea Islander ancestory? yes no
Are you of Aboriginal or Torres Strait Islander origin? yes no
Yes—Aboriginal (please tick)
No
Yes—both Aboriginal and Torres Strait Islander
Yes—Torres Strait Islander
(adapted: Queensland Health Statewide Patient Satisfaction Survey: State Report. 2006)
An Interview Guide (Table 8) was included in the information packages
to ensure that the participants understood the scope of the study. A risk
identified at the beginning of the study was that participants may view the
process as a means of having their causes championed. The interview guide
provided clear boundaries and expectations.
A total of forty-seven information packages were distributed to interested
parties. Twenty-two participants requested to proceed with the screening process
for inclusion in the study. Exclusion criteria concluded that four participants of
the twenty-two participants were unsuitable because their inpatient stay and
complaint concerned another state in Australia, or because the issue had
occurred outside the acute health care sector.
Chapter 3: Methodology, Design and Methods
89
Although eighteen participants were selected for inclusion, two were
unable to continue participating in the study. The first withdrawal was a result of
complications from a stroke which caused the individual to suffer from aphasia.
The second withdrawal occurred because the individual moved from
Queensland. The final sixteen participants had all been provided with
information packages that included information about the study, the consent
process, an interview guide to the types of questions that could be explored in
the interview, and a request for some demographic information.
3.5.3. Interview Guide
Table 8: Complaints Study—Interview Guide
Complaints Study—Interview Guide (Howard, 2007)
1. Can you tell me about the reason/s why you made a complaint about your
hospital stay?
2. Can you tell me about your knowledge of the hospital complaint system?
3. What type of encouragement did you receive from the staff to provide
feedback regarding your care throughout your hospital stay?
4. What aspects of the complaints handling system were you especially
satisfied, or dissatisfied, with?
5. Can you tell me how what happened to you has affected you—for example,
inconvenience, personal trauma, physical or psychological issues?
6. Can you tell me what you hoped to achieve by making a complaint?
7. Can you tell me about any barriers you faced having your complaint heard
or resolved?
8. Can you make any suggestions for better management of how your
complaints or the process in general should have been handled?
9. Can you tell me about the emotions you experienced while you were
engaging in the complaints process and after you lodged the complaint?
10. Can you tell me about what coping strategies you used while you were
Chapter 3: Methodology, Design and Methods
90
Complaints Study—Interview Guide (Howard, 2007)
engaging in the complaints process and after you lodged the complaint?
11. If you were able to improve the complaints handling process what would
you recommend?
3.5.4. Thesis Process and Interview Timeline
Following ethics approval in July 2007, the following table (Table 9)
provides an overview of the actions undertaken with the proposed dates and the
actual completion status. While the actual end date of the study was extended by an
extra year (due to deferment), the original issue is no less relevant today than it was
in 2005 when the thesis proposal was first formulated.
Table 9: Thesis Process and Interview Timeline
Thesis Process and Interview Timeline
ACTION Proposed to be
completed
Actual
completion
Approvals/ethics application completed,
design & sampling strategies completed.
Literature review commenced. Stage 2
confirmation completed (see Appendix: X
for confirmation seminar notice).
June 2007 July 2007
Literature review & write-up completed. Oct 2007 Achieved
Recruitment for study participants to begin.
Potential participants identified n = 47
Patients screened for eligibility n = 22
Nov 2007 Achieved
Data Collection (Interviews) to be
commenced.
Excluded from study n =4
Met inclusion criteria n = 18
Dec 2007—June
2008 Achieved
Chapter 3: Methodology, Design and Methods
91
Thesis Process and Interview Timeline
Analysis of Interviews to be commenced.
Participated in study n = 16
July 2008—Dec
2009 Achieved
Dissemination of preliminary findings at
Conferences.
Jan 2009—Dec
2009 Achieved
Thesis Draft to be reviewed June 2009 Achieved
Thesis Draft 2 to be reviewed June 2010 July 2010
Thesis Draft 3 reviewed and edited Aug2010 Oct 2010
Final seminar (see Appendix: Y) for final
seminar notice). Oct 2010 Nov 2010
Submission for examination Jan 2011 Feb 2011
3.6. STEP 3—PROVIDING FOLLOW-UP
The primary feedback and information update process was facilitated by the
webpage www.complaints-study.org. This webpage was developed, maintained,
and updated by the author of this thesis as new information became available. All
participants were provided with the webpage URL and contact details if they
required any further information about the study. Following the interviews no
further contact has been made by any of the participants. Details of all research
activities involving dissemination of the study via the conferences attended were
also uploaded to the webpage.
3.7. DATA ANALYSIS
3.7.1. Introduction to the Analysis
From a phenomenological perspective, this study has attempted to
explore what the experience of complaining was like for the participants, what
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the experience of complaining actually meant to them, and how their
engagement in that process affected their lifeworld. The role of the author in this
process was to help the participants express their experiences as directly as
possible; and then the challenge was how to explain these factors so that their
lifeworlds could be revealed.
An interpretative phenomenological analysis (IPA) was undertaken to
understand the experiences of patients, carers or patient advocates who had
complained about some aspect of their hospital care. IPA involved an
exploration of the processes through which the participants made sense of their
experiences. This was achieved by an examination of the personal accounts
shared during the interview process (Findlay, 2009; Larkin, Watts, & Clifton,
2006; Smith & Osborn, 2003).
There are distinct levels in the analysis process. The first level can be
viewed as the naïve reading. Lindseth and Norberg (2004) provide a detailed
account of the first level of the process, where the interview transcript is read
several times over. The rationale for this is to try to grasp the overall meaning of
the text. The understanding that is gained at this level guides the next level of
structural analysis. At this level, themes were determined in context with the
first level of understanding, and then they were further condensed to ‗validate or
invalidate the naïve understanding‘ (Lindseth and Norberg, 2004, p. 150).
Finally, a table of sub-themes was developed and the interviews were examined
in relation to the emerging common themes of the interviews to reveal the
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superordinate themes that were either shared or not. All participants of the study
were assigned a unique identifier number and a pseudonym. The following table
details this information.
Table 10: Participant Identifier and Pseudonym
Participants Identifier and Pseudonym
Order Interviewed Identifier Pseudonym
Complaints study participant 1 CSP01 Nick
Complaints study participant 2 CSP02 Isabella
Complaints study participant 3 CSP03 Michael
Complaints study participant 4 CSP04 Mia
Complaints study participant 5 CSP05 Grace
Complaints study participant 6 CSP06 William
Complaints study participant 7 CSP07 Audrey
Complaints study participant 8 CSP08 Madeline
Complaints study participant 9 CSP09 Andrea
Complaints study participant 10 CSP010 Charlotte
Complaints study participant 11 CSP011 Katherine
Complaints study participant 12 CSP012 Emma
Complaints study participant 13 CSP013 Jonathon
Complaints study participant 14 CSP014 Samuel
Complaints study participant 15 CSP015 Ava
Complaints study participant 16 CSP016 Zoey
3.7.2. Undertaking the Analysis of the Data
The analysis process consisted of the following stages:
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3.7.2.1. Transcription
The transcription process was undertaken as soon after the interview as
possible. The average duration of the interviews was forty-five minutes. There
were significant variations in the word count per interview which was dependent
on the participant‘s speed of speech. Overall, there were a combined total of
62,000 words in the narratives; journal entries and notes added another 1500
words. The findings extracted from the data and presented in this thesis have
been included to enable readers to gain insight into the worlds of the study
participants.
3.7.2.2. First Level Reading
Once the interviews were transcribed, each individual narrative was read
to ascertain an overall impression of the content. This process provided the
scaffold that underpinned the direction of all the subsequent analysis. The
participants were vivid in their descriptions of the issues that preceded their
complaints. These prominent impressions clearly emerged from their narratives.
3.7.2.3. Structural Analysis
While overall impressions had clearly emerged very early on in the
interpretative process, the process of reading and re-reading the text continued.
A line by line approach was taken with all of the narratives. Each line, each
word, and each phrase was considered in the context of the language being used
and the relational meaning with the emotions identified as part of the contextual
connection. A different colour was assigned to a word, or a phrase that reflected
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a concept and emerged into a theme. Appendix G provides an example of the
coding process that began during this stage and continued through the following
two stages.
3.7.2.4. Relational Themes and Emergence of Superordinate Themes
The focus of the analysis was the identification of relational themes.
While all of the narratives were unique in their representation of their
experiences, they were also connected by common relational themes. Most of
the narratives featured repetitions of the same sub-theme, with only slight
variations in the wording; the principle representation of that sub-theme is what
was extracted to represent the relational theme. The identification of these
relational themes supported the emergence of the superordinate themes. This
part of the process may appear quite confusing; however, an examination of the
table which collates these themes in Appendix H, clarifies the way superordinate
themes emerged. Five superordinate themes emerged though this process. The
identification and relevance of these superordinate themes will be discussed in
detail in chapter 5.
3.8. ESTABLISHING RIGOUR
Attention to methodological rigour for this study has been guided by the
direction provided by Sandelowski (1986), who proposed that ―qualitative
inquiry may be viewed as blending scientific rules and artistic imagination‖
(Sandelowski, 1986, p. 29). It is this ―artistic imagination‖ that at times can
easily influence a deviation from ―expected‖ methodological rigour. While it is
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important to maintain the artistic foundation that qualitative research offers, one
must also be prepared to be transparent and credible in the methodological
approach taken. However, this pursuit of methodological rigour has been
problematic and difficult to strike a balance at times. De Witt and Ploeg (2006)
cited dozens of authors who all agreed as to the controversial nature of
establishing rigour in phenomenological research. Whilst undertaking this study
there have been many occasions where conflicts have occurred concerning
wanting to adhere to ―known‖ or ―expected‖ criteria of rigour, yet
acknowledging that these were sometimes at odds with the interpretive nature of
the methodology used.
In terms of ensuring objectivity of the data and the analysis many IPA
studies involve multiple reviewers to ensure similar clustering and interpretation
of the text (De Witt & Ploeg, 2006). However, this approach was not used in this
study. A strong need to keep the interpretative nature of the narratives closely
connected between the participants and the researcher naturally occurred. It was
felt that other influences, such as other reviewers might diminish or alter the
thematic interpretations that emerged. Whilst this was the approach taken,
recognition of this deviation from a traditional approach to undertaking the
hermeneutic circle as part of the interpretative approach to this study was
identified as a potential limitation. Alternative options were examined by the
author to identify whether there were any other processes that could be more
appropriate and objective to assist in validating the data being examined.
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The use of a text analysis software tool in combination with the IPA
approach was considered to be an appropriate alternative to using multiple
reviewers. The software, developed by the University of Queensland, is called
Leximancer™ and is a tool that can be used to analyse the content of collections
of textual documents and to display the extracted information visually. The
information is displayed by means of a conceptual map that provides a bird‘s-
eye view of the material, representing the main concepts contained within the
text and information about how they are related. The map also allows one to
view the conceptual structure of the information, and to perform a directed
search of the documents in order to explore instances of the concepts or their
interrelationships.
3.9. SUMMARY
The methodological process used to explore this phenomenon, while being
appropriate, was also very challenging. Several potential limitations have been
identified that may need to be taken into account and applied to future research
directions as a result of this study. While undertaking a phenomenological
exploration you get the sense that it is a free-flowing event that you are conducting.
However, the main message of this chapter is that while this process is fluid,
interpretative, and iterative, one must be cautious to apply appropriate attention to
every aspect of the methods used to ensure that the findings are valid, reliable, and
transparent.
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98
Chapter 4: Findings—Assigning Meanings to
the Words
4. INTRODUCTION
The previous chapters have provided insights into the issues related to
complaints handling and, in particular, what may occur if complaints are not
handled correctly.
Chapter 4 presents all of the outcomes of the study, commencing with the
demographic findings. These will be followed by the findings collected from the
narratives and journal notes, and thematic considerations identified about each of
the participants. The structure of this chapter is based on the contextual
framework introduced in Chapter 3. A table indicating a snapshot view of the
primary issue, the sub-themes identified, and the superordinate themes identified
are included at the end of this chapter.
―Your most unhappy customers are your greatest source of
learning‖ Bill Gates (1955 - ).
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4.1. EVERYDAY WORLD
4.1.1. Description of the Participants
The sixteen participants involved in this study all opened themselves up on
many levels and it is through these exchanges that their everyday worlds have been
explored. While the narratives are the focal points of this study, important
information can also be ascertained by understanding how the individuals concerned
are represented and live in the ―world‖. Of the sixteen participants, five were males
and eleven females. A higher participation rate was represented by females than
males by a ratio of 2:1.
Table 11: Complaints Study Participants—Gender
Gender
Male n = 5 (31%)
Female n = 11 (69%)
The following table reveals the participant‘s focus as being either the
actual patient or advocate speaking on behalf of the person who had experienced
the negative situation which resulted in the complaint being made.
Table 12: Complaints Study Participants—Patient/Advocate
Participants n = 16 (100%)
Actual Patient made the complaint n = 13 (81%)
Advocate of Patient made the complaint n = 3 (19%)
The spread of participant inclusion by age reveals that the youngest
participant was a twenty-three-year-old female, and that the oldest was a
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100
seventy- eight year old female. The mean average age of the participants was
49.4 years, with a standard deviation of 17.3.
Table 13: Complaints Study Participants—Age
Age Group
18-24 years n = 1 (6%)
25-34 years n = 2 (13%)
35-49 years n = 5 (31%)
50-64 years n = 4 (25%)
65-79 years n = 4 (25%)
80 years and over n = 0 (0%)
While the demographic findings reveal a representation of participants
who made a complaint emanating from a variety of admission needs, the
findings do reveal potential limitations. The participants were only
representative of English speaking participants from Australia, England, and
New Zealand. The study did not involve any representatives from culturally and
linguistically diverse (CALD) groups or any participants from Australian South
Sea Islander, Aboriginal, or Torres Strait Islander ancestry.
Table 14: Complaints Study Participants—Country of Birth
Country of Birth
Australia n = 12 (75%)
UK n = 3 (19%)
New Zealand n = 1 (6%)
Greece n = 0 (0%)
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Country of Birth
Italy n = 0 (0%)
Other—please specify n = 0 (0%)
The participants of the study made more complaints about public
hospitals than private hospitals by a ratio of 3:1. Of the sixteen participants 25%
of the complaints were as a result of an inpatient stay at a medium hospital, 31%
from a principal/referral specialist hospital, and 44% from large hospitals. The
peer grouping criteria is included in Appendix I.
Table 15: Complaints Study Participants—Type of Hospital
Complaint Origin According to Peer Grouping
Principal Referral & Specialist Hospital n = 5 (31%)
Large Hospitals n = 9 (56%)
Medium Hospitals/Small and Rural Hospitals n = 2 (13%)
While all participants made a verbal or written complaint to the hospital
where the complaint occured, five also lodged a written complaint with the
Health Quality Complaints Commission, and two other participants involved
other agencies.The agencies are identified in the following table.
Table 16: Complaints Study Participants—Other Agencies involved
Agencies Involved in Complaint
Original Hospital where Complaint Originated n = 16 (100%)
Ombudsman n = 2 (13%)
Member of Parliament n = 3(19%)
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Agencies Involved in Complaint
Crime & Miscondunct Commission n = 2 (13%)
Quality & Complaints Commisssion n = 5 (31%)
Legal Aid n = 3(19%)
Mental Health Services n = 2 (13%)
Department of Child Safety n = 2 (13%)
4.2. SETTING THE SCENE
4.2.1. Presentation of Findings
The following data are provided using pseudonyms for all of the
participants in this study. The following synthesised descriptions illustrate the
participant‘s experiences in relation to Lazarus‘ cognitive emotive model of
coping as described in section 3.1.7. Table 17 at the end of this chapter provides
a snapshot of the participant‘s details, the issues surrounding the complaint, and
emerging and superordinate themes identified.
4.3. SEEING THROUGH THE EYES OF OTHERS
4.3.1. Emotionally Significant Event
The following findings present the memories that the participants identified
and shared as being the significant event that precipitated the complaint being made.
These findings will illustrate the variations in individual‘s thresholds. The events
described by the participants ranged from catastrophic events (which in some cases
led to death) and, at the other end of the spectrum, to events where the participants
were treated rudely. The connection between the participants was that the
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experience that precipitated the complaint was the significant event for them, and
that the actual trigger of the complaint did not diminish its significance to that
individual.
Figure 5: Cognitive Appraisal Process Identification of the Situation/Event
December 2007 marked the commencement of the interview process.
Nick, a 55-year-old male born in the United Kingdom, had been an Australian
resident for approximately fifteen years. Nick made contact via the webpage after
seeing the advertisement in his local paper. After receiving a participant package,
Nick rang and confirmed that he wanted to be part of the study.
The interview was conducted in the dining room of Nick‘s house. After
talking briefly to both Nick and his wife, his wife then left the room so that the
interview could proceed. Nick had been an inpatient of a large private hospital. His
principal complaint related to a procedure that he had undergone as part of the
treatment for a shoulder injury. The issue of concern related to the way the
technicians interacted with him as the patient. Nick felt that he was treated very
rudely by the radiographer and technician involved in undertaking the X-ray. The
Situation/
Event
Primary
Appraisal
Secondary
Appraisal
Appraisal
Outcome
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104
situation was so upsetting to him that he wrote a detailed letter of complaint to the
radiography department.
4.3.2. Where Has All the Good Service Gone? Nick & Emma
The following extract is Nick‘s immediate response to the question ―...can
you tell me about the reason why you made a complaint in the first place?‖
(Nick)...Well, the reason I made a complaint in the first place
is because I did not actually like the way that I was treated. I
was treated, I felt like a piece of meat. I was there as a toy so
that they could play with their new piece of software so they
could test their new machine instead of rather than looking at
the patient who actually had a problem that needing sorting
out and that really irritated me and annoyed me ...
This response was very forthright, from the outset it was obvious that Nick
had very clear thoughts about what he perceived as being appropriate or
inappropriate treatment. The transcription notes reflected a moment of silence after
this reply. A side note stated very confident person, straight to the point, well
spoken. As the interview progressed, Nick‘s tone and demeanour settled, this was
evident in his verbal and non-verbal communication. Of the sixteen participants,
two had very similar experiences involving radiology departments in two different
major hospitals.
Emma, a forty-eight-year old female, first saw details about the study in
her local newspaper. She then visited the website to gather more information about
the background of the study. She used the contact process via the webpage to
request an information package. The information package was sent in the first
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week of December, 2007. A consent form was returned via the stamped self-
addressed envelope, with a request to undertake the interview in January, 2008,
with the actual date to be confirmed. A follow-up phone call was made and Emma
requested that the interview be rescheduled until February, 2008 as she was going
on a short holiday in January.
Emma arranged to undertake the interview at her place of employment,
where she works as a supervisor in a customer-focused environment. It is
interesting to note that before the interview started, Emma mentioned that she
credits her knowledge of consumer satisfaction for her appreciation of what, in her
opinion is, good and bad service. However, despite having this experience in
customer service, she did say that she worried about being perceived as a
―whinger‖.
Emma was asked ―Can you tell me about your experience‖? Like Nick,
she did not hesitate in getting straight to the point and she was very forthright
about what she considered to be good service. Journal notes indicated that Emma
and Nick both work in professional environments where strong quality
management principles influence organisational processes. O‘Shaughnessy (2009)
discusses interpreting behaviour and determining the reason why certain things
influence us and other things do not. He proposes that ‗the notion of something
having meaning or significance for the consumer is conceptually linked to things
about which the consumer is concerned‘ (p. 56). The customer service standards
that Nick and Emma expect from themselves and their customers are perhaps why
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they responded the way that they did. The experience for Emma was also
heightened by the level of pain and the lack of control she was experiencing.
(Emma)... I had severe pains in the back of my head, that had
gradually worsened over the last three days,... the GP asked me
a lot of questions ... he said to me to get down to the hospital
as soon as possible so I rang my husband and got him to meet
me at home....
(Emma)... He gave me the paperwork to get a cat scan as soon
as I could. So, we fronted up there and I took overnight things
as well because the doctor said be prepared to stay overnight.
The hospital‘s radiology receptionist was very rude and she
said ‗well you can‘t get in today we haven‘t got anything for
you today‘, so then we explained what the doctor had told us
and the urgency of it...
(Emma)... The whole time I was worrying, in pain and
wondering what was happening to me but they didn‘t say a
thing about any delays or anything I just didn‘t think that was
very good customer service. I had to actually go up to the
counter and ask when I would be going in, and then obviously
they were rushed the radiologist that came and took me
through was very short and very rushed and didn‘t seem to
care that I was in pain, he just pushed me back to lay down for
the scan ...
Nick was asked whether anytime during the x-ray process he said anything
to the staff who he perceived were treating him ―like a piece of meat‖.
(Nick)... I put up with it because I was in pain and I was
hoping to get a resolution to the fact that my shoulder was
causing me a lot of discomfort and it wasn't until afterwards
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when the pain subsided and I started to think about the way
that I had been treated ...
Emma also acknowledged the influence that being in pain had on her
capacity to cope with the situation. While Emma‘s anxiety increased, Nick became
introspective and did not react as he felt he should have. There was also a sense that
Nick was shocked by his experience and that perhaps it is why he did not react the
way he felt he should have. (Nick)... I found it extremely degrading...
4.3.3. For Our Loved Ones: William, Audrey, Michael, & Isabella
The next group that shared similar triggers and coping mechanisms was
demonstrated in the participants who represented the advocate role in this study.
Two of the advocates were speaking out to share the story of a loved one who, in
their view, had died as a consequence of negligence on the part of hospital staff. The
third advocate was in a relationship with one of the participants (Isabella) who
required significant support to have her concerns raised and heard. The three
advocates shared similar characteristics that became evident during the analysis
process. These three participants kept detailed notes, letters, and correspondence
from a variety of people that they had for assistance with their concerns. They were
insistent that each of their letters and responses was read so that the full story could
be understood. Expressions of desperation and exasperation were most pronounced
in the narratives of these three participants.
Most notably, the experience of William and the despair and trauma that
he had suffered since his wife‘s death truly captured how events can transpire so
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catastrophically as a consequence of one single action. William‘s interview was the
only one conducted over the phone. William had initially made contact on
November 27, 2007, after seeing the advertisement in his local paper. That initial
phone call lasted for approximately thirty minutes during which William related his
story and expressed his willingness to be involved in the study. William was
advised that a meeting time could be organised for the next visit being made to the
city in which he resides. That was to occur approximately five to six weeks later, in
the New Year.
Two weeks after receiving William‘s initial phone call, a call was received
from a well known Queensland consumer advocate who asked whether the
interview with William could be conducted over the telephone. The consumer
advocate, with whom William had already established a strong relationship, had
made contact because William had expressed fears that ―he would die before getting
a chance to tell his story‖ (Consumer advocate, personal communication, December
15, 2007).
William was contacted later that day. A confirmation was received from
him, indicating that he had received the information package and that he was
providing verbal consent to proceed with the interview. A phone interview was
scheduled for the next day. After confirming that William was comfortable and
ready to begin, the telephone interview lasted for just over an hour. The opening
question invited William to share his complaint experience. William responded
with:
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(William)... I have repeated this story so many times that it
has just become part of my life and I live with it every day and
I wanted to tell you because like I said I don‘t think my time
here is very much longer ...
William was advised to take his time and to take breaks when needed.
(William)... Well, it all started back in 2003, December the
third actually; Gloria my wife had a heart attack at home. I
swear her death was preventable and the doctor and nurse
involved in her care should have been subject to disciplinary
action. I still remember Gloria waking me just after midnight
and saying ―you will have to take me to hospital‖ She told me
she already had taken her spray under her tongue and had
taken some aspirin but she said she was still in a lot of pain. I
called for an ambulance, because that‘s what Gloria wanted
and it got to our home quickly, there were two paramedics.
One of the paramedics gave Gloria an aspirin and some spray
under her tongue. Gloria was then taken to the hospital. I got
into my own car and followed behind in my car. When Gloria
got to the hospital, the staff there sprayed under her tongue
again and gave her another aspirin. I remember hearing the
nurse ask Gloria how she was feeling and Gloria said that the
pain was easing.
William‘s account of that day was very detailed and he was able to recall
minute details, for example:
(William)... I think it must have been around eight o‘clock in
the morning. Not long after I got to the ward the specialist
arrived it was about half an hour later. I told the specialist that
I had just come back from the X-ray unit and that Gloria was
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still booked in to be seen if he wanted the tests done, but I told
him that the X-ray unit needs to be notified straight away. The
specialist then told the nurse that was there that he wanted a
test to be done straight away. I had Gloria‘s appointment card
and I pointed out to the nurse the number to call to verify that
we still wanted to keep the appointment. She went off without
speaking to me, so it looked like she was going off to make the
arrangements...
This event was the defining moment for William and the antecedent of the
grief that he harbours over his wife‘s death. Later in the day William went to
enquire about his wife‘s X-ray appointment. The doctor advised him that the
appointment could not be made that day and that they would have to wait until
another appointment could be arranged. The doctors advised William that since
Gloria was stable, she could be discharged and return home. He explained that once
Gloria had taken the stress test and he had viewed the results he would be in a better
position to recommend treatment options.
(William)... at this point I was just very angry that my wife wasn‘t
getting the care that she deserved... I said straight away to him that
now I am confused less than ten minutes ago you were talking to me
like my wife was in an emergency, what‘s changed, he didn‘t give
me any answer. It wasn‘t long after that I saw the nurse that was
with the doctor in the morning and was supposed to verify the
appointment. I said to her why she didn‘t make the call, you know
what she said, she said it‘s not my job the doctor should have made
the call. Can you believe that?
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Later that afternoon, Gloria was assessed as being stable enough to be
discharged and sent home, but William was not happy with this situation.
(William)...When we got home I said to Gloria, let‘s just
book a plane to Brisbane and go and see the specialist at
XX Hospital. Gloria said no, it is all right the hospital
knows what they doing, so we stayed. Gloria went to bed
because she was very tired I checked on her regularly
before going to bed myself. I spoke to Gloria it must have
been around four-thirty in the morning; I heard she was out
of bed. I asked her if she was okay, she said she was just
going to the toilet. It was just on six in the morning when I
went into see Gloria, but she had died, I used my oxygen on
her and I tried to give her mouth to mouth resuscitation but
I couldn‘t revive her. I called for the ambulance when they
arrived the paramedic said it was too late she was gone ...
After Gloria was taken, I was just so angry and in disbelief,
I went to the police station. I went over to the CIB and said
to them that I wanted the nurse and doctor charged with
causing the death of Gloria...
No action was ever taken by the Police department, despite William‘s
continual pursuit to have criminal charges laid against the hospital staff involved
in this situation.
The next advocate was Audrey, who had faced similar struggles trying to
ensure that her father received (the best of) care. First contact was made by Audrey
on January, 17, 2008. She had seen the advertisement seeking study participants in
her local paper and rang to ascertain some more details about the study. That initial
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phone call lasted for approximately fifteen minutes, during which she discussed the
complaint that she had lodged at her local hospital following the admission of her
father. Audrey‘s father never returned home from that admission—he died in the
hospital. Audrey spoke about the mismanagement of her father‘s care, and the poor
standard of nursing care that he had received. She stated that these were all
contributing factors to his death. During this discussion arrangements were made for
the interview to be conducted on January, 22, 2008. Audrey was interviewed in the
context of being an ―Advocate‖ to relay her father‘s story. An information package
was not able to be sent out in the time between first contact and the scheduled
interview, and the initial interaction with Audrey involved going through the
information package and signing the consent form.
Audrey wanted to display the letters that she had sent to, and the subsequent
responses that she had received from the hospital in question. The responses that she
received did not satisfy her, nor did the hospital provide supporting statements as to
why certain issues concerning her father‘s care occurred. As was the case with
William, the need to display and present all the efforts that had been made to raise
awareness of the situation was a significant focus for Audrey. Audrey responded, to
the question, ―can you tell me about the reasons why you made the complaint
concerning your father‘s stay in hospital XX‖? As follows:
(Audrey)... I made the complaint about when my dad was in
XX hospital because primarily I felt that it wasn‘t handled
well dad was an elderly man who had what you call, classed as
transient strokes so he had got all his faculties back after he
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had his stroke he was put into the medical ward, the medical
ward at that time was too full so they transferred him to a
rehab ward from the word go the hospital staff he was put on
digoxin and the hospital staff were not doing anything about
trying to get him out of bed so the one of the first issues that I
came up with my dad was I spoke to the nurses and I said if
dad was just left in bed he was going to lose his mobility he
successfully managed to stay in his own unit and I knew that
was what dad had wanted to do...
A small break was required, as Audrey started to cry. She quietly said ―Dad
struggled to maintain his independence, that‘s why this was so sad‖ Audrey showed
me a photo of her father from the previous Christmas when he had enjoyed the
company of his family, and was still relatively independent. ―This is how I want to
remember him‖ she said.
The third advocate in this study was quite unique. Michael requested to be
part of the study in his capacity as an advocate for another study participant,
Isabella. While Isabella and Michael were interviewed together, they had very
distinct stories to relate. It was Michael who first made contact via telephone after
reading the advertisement requesting study participants. Details of the study intent
were discussed over the phone and details taken to forward an information package
to him and Isabella. A follow-up phone call was made a week later and a meeting
was arranged. The interview was conducted in Michael and Isabella‘s home on
December, 8, 2007.
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The initial interaction occurred with Michael and it was at this time, while
we waited for Isabella to join us that he wanted me to review all of the
correspondence that he had accumulated over the previous twelve months from
various agencies. As in Audrey‘s case this appeared to be a way for them to prove,
right from the beginning, that they had done all they could. At no time was there any
request for them to verify their accounts—they were automatically presented, as if
for inspection. The opening dialogue with Michael was to talk about their situation.
(Michael)... Well, our story is twofold; no it‘s threefold,
maybe four. It‘s, yeah well there‘s the problem with this nurse
from XX service, that‘s one issue, the other issue, which really
will have nothing to do with you, is with the legal aid and the
legal system, and the other issue is with the department of
dingoes, you know child safety...
From the outset, it was obvious that Michael had endured many struggles
faced many hurdles throughout his life. He was very aware of his inability to be able
to meet these challenges and on many occasions told of his difficulties in being able
to manage his and Isabella‘s affairs.
(Michael)... our difficulty without any knowledge of this,
and the amount of knowledge you need for this is vast and
without legal representation or anything like that it‘s up to
one person and that‘s me, one person to do the whole lot,
like whatever, everything and that‘s dealing with the CMC,
uh the Department of Mental Health, we are dealing with
the ombudsman and we are dealing with some other mob,
uh….Queensland Health, the Minister of Queensland
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Health and we are also dealing with the Minister of Child
Safety, after that it‘s a piece of piss...
Michael was very open and genuine in his responses and he did not
censor his language. He did not hold back information about his relationship
with Isabella. Michael and Isabella are married and Michael is the stepfather to
Isabella‘s eighteen month-old daughter. The focus of the issue for Michael and
Isabella was the removal of their daughter from their care. During an inpatient
stay, Isabella was diagnosed with post-partum depression, with potential for self-
harm. At that time the baby was removed from her care, without any
consultation or preparation. Michael was not the legal stepfather at that time and
was not able to officially assume care while Isabella recovered. Their child is
currently in foster care, and they struggle to elicit a response from the hospital as
to how a child can be removed in the manner that ―bubs‖ was taken from them.
Isabella certainly blames herself for getting sick but she is also very confident
that one particular nurse from the hospital had gone out of her way to ensure the
child‘s removal.
(Isabella)... Nurse X said to two people—Government
officials—that people who have a mental illness or a
disability should not have children. And that‘s her attitude:
that they should be removed...
4.3.4. It's Not Just About Me: Andrea, Charlotte, & Zoey
The next three participants revealed how individuals can survive in the face
of adversity when ‗significant others‘ are involved. All three of these women shared
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the experience of pregnancy, but each had a very different situation that triggered
the event that was shared.
Andrea is a thirty-year-old female who resides in a rural country town
approximately 200 kilometres from Brisbane. She made contact by phone on
December, 20, 2007, after seeing the advertisement in her local newspaper.
Arrangements were made for an information package to be sent and a follow-up call
to be made by the researcher in the first couple of weeks in January 2008. This
phone call was made, Andrea confirmed that she had received the information
package and would like to organise an interview time. The offer was made for the
researcher to travel to Andrea‘s town, but she was organising a trip to Brisbane to
visit her sister in mid-January. The interview date was set for January 23, 2008 at
Andrea‘s sister‘s house.
On meeting Andrea, the deep sadness that she still harboured concerning her
incident was immediately apparent. Andrea spoke quietly and displayed minimal
facial expressions throughout the hour of the interview. Her speech was slow and
considered, and she took many pauses between words. So, while the actual
interview time was well in line with other interviews, the amount of data was well
below comparatively timed narratives. Despite this, the narrative was still rich in
description and very clear thematic considerations surfaced. The most notable
variation from other participants‘ emotional contexts was that there were no positive
emotions expressed throughout the interview. The overwhelming emotions of anger,
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117
anxiety and sadness permeated the entire narrative. Andrea was asked to talk freely
about the reasons for her complaint.
(Andrea)... Okay, I made a complaint almost three years
ago. I had my son delivered by Caesarean section which at
the time we were sort of, it was a rushed situation and we
gave no consent and we were definitely not given any
information in any way, we sort of were just moved into a
room and we thought at the time that something must have
been really wrong and then after it was all sewn up and
everything the doctor came in and said that he felt that I had
been in labour long enough. That was his only reason for
the Caesarean. So I made a complaint because I felt we
were treated badly and I didn‘t have the opportunity to give
informed consent and that there was actual no clinical
evidence for the need for the Caesarean other than the
doctor thought that I had enough time, which to me is not
justifiable for a major operation.
While Andrea was able to acknowledge that she had a healthy child, she
was not able to come to terms with how the birthing process was managed.
(Andrea)... When I was on the trolley I kept saying to the
midwife I don‘t want this, this is not what I want to happen
and so on, the other thing was that my son was taken away
because they said it was routine practice so he was taken
away with my husband and the midwife apparently said to
my husband oh I am so worried about your wife, she is so
distraught about having the Caesarean but no-one actually
never said anything to me at all.
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The next participant is Charlotte, a thirty-one-year-old female, married
with two small children, and who lives in a small south-eastern rural community
approximately 120 kilometres from Brisbane. Charlotte made contact via the
telephone in mid December 2007. A friend of hers had seen the advertisement in the
local paper and passed it onto her. A discussion lasting approximately fifteen
minutes ensued, and she requested an information package. Charlotte asked to be
called in the New Year to organise an interview time. A follow-up call was made on
January 17, 2008, with a date confirmed for January 24, 2008 to conduct the
interview.
On meeting Charlotte she was very inviting, smiling and welcoming into her
home. The oldest child was playing near the television and the baby girl—the focus
of the incident— was having her morning nap. After settling in the kitchen,
Charlotte began to relate her story. A note made in the personal journal of the
interviewer straight after the interview was a single statement: OMG! (Oh My God).
This remark captured the overwhelming sense of helplessness and sheer frustration
felt after this interview in relation to how the system failed this person so
completely.
Charlotte‘s story was of a person in crisis and in pain, who had sought help
from a system that was supposed to provide it, but which totally failed to identify
and respond to her needs. Pregnant and complaining of abdominal pain, she had
endured acute appendicitis, and was turned away, on two occasions, by a local
hospital on the premise that she had a urine infection. The long-term effects of this
Chapter 4: Findings
119
incident are yet to be fully realised and this has added to the depth of the emotions
experienced and identified in the narrative.
(Charlotte) ... the doctor did not touch me he didn‘t examine
me I was, the heart beat of the baby wasn‘t checked or
anything like that because the second day I was in huge
amounts of pain I would have thought that he would have
been a little bit more attentive than he was and the nurse that I
dealt with also was very uninterested when I went in the
second day she said Oh! Your colour is better than yesterday.
It was the first comment she said, that your colour is better
than yesterday. I just thought to myself, Oh come on. They
ended up sending me home saying that I had a urinary tract
infection so they never listened to my breathing, they never
listened, I don‘t believe they checked my temperature just the
general things that I would have thought would have been
standard procedure...
So far with this group of women there is a healthy baby delivered by
Caesarean section against the mother‘s wishes, there is a baby in utero who was
endangered because of a misdiagnosis, and then there is Zoey‘s story, and her
stillborn son, Luke.
(Zoey)... I had an induction date booked ... I went into labour...
I hadn't dilated enough ... sent home ... came back that
evening... still hadn‘t dilated very much as I remember, I was
given some pain killers and sent home again...
... I was in so much pain. I remember in the morning my legs
were just shaking I didn‘t have, I only got some sleep but only
a little I was just so worn out, I was in tears I was just so
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distressed we rang the hospital but the hospital was extremely
dismissive ...
... My pain was continual I felt that my contractions were
continual and it was said that during your antenatal classes
about the timing and if that happens you are told to come in.
You go in and then they say oh well we want them to last a
good forty-five seconds to a minute as well and I just couldn‘t
understand myself how by having them at these seconds was
going to change anything I was getting quite distressed ...
...The hospital wasn‘t considering my pain very well, I was
getting so distressed and I was now having continual
headaches...the midwife said I wasn‘t in true labour...
... I went in three times... I finally was admitted and went to an
observation room where they hooked me up to a monitor, the
obstetrician came in and saw I was obviously in distress, she
did an internal observation and said I was dilated at 3-5cms,
she said we can progress you at this stage and asked me how I
felt about having a epidural, this is now about eight o‘clock at
night ... about an hour later I was up to go to the toilet and this
is where it began I was just bleeding, it was a massive amount
of blood, when I came out into the room people just seemed to
be running from everywhere...it was just so much confusion it
just seemed so unreal they hooked me back up to the monitor
and there was no heartbeat for the baby, they then got another
machine a ultrasound and they did locate a heartbeat but it was
very slow, the obstetrician said we need to do an emergency
caesarean ...my husband was just standing there looking so
scared as everyone was just rushing around the room... it was
just full ...it just happened so quickly...
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Crying, Zoey then described how she had had photographs taken with her
still born son while in the operating theatre room.
4.3.5. I Deserve Proper Care: Mia, Grace, Madeline, Katherine, Jonathon,
Ava, & Samuel
Mia is an Australian-born sixty-nine-year-old woman — A widow of ten
years, with a married daughter who has three children of her own. Mia had a lengthy
career as a nurse and provided a lot of reflections on how things were done ‗in her
day‘. Mia‘s original complaint had been made two years previously, following
major surgery in a private hospital. She saw the advertisement in her local paper and
had spoken at length with her daughter about whether she should make contact. Mia
had not realised how much hurt and angst she was still holding about that particular
incident; that was what motivated her to make contact. Two lengthy phone
conversations occurred over a period of a week, and it was during the second phone
conversation that Mia stated that she wanted to meet and to be part of the study.
Arrangements were made to meet at a coffee shop in Garden City Shopping Centre
on December 13, 2007. A table at the rear of the coffee shop was chosen to ensure
sufficient privacy and so that the interview could be recorded with minimal
interference from external noises in the shopping centre.
The interview lasted for approximately thirty-five minutes. With the benefit
of hindsight, conducting the interview in a coffee shop produced limited results.
Both participant and researcher were very conscious of being in a public space,
which may have hindered the conversation and limited the time spent conversing.
Mia brought the original letter of complaint that she had sent to the hospital
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122
expressing her dissatisfaction with the care that she had received following her
surgery. She stated that she had received no response to her letter. Mia felt that the
lack of acknowledgement and action from the hospital was the primary reason why
she has not been able to move on and why she still harboured very negative feelings
regarding her hospital experience.
(Mia)... Well, I had surgery for bowel cancer in 2005 and I
wasn‘t very happy with the hospital ... ... so it was a few years
ago now but it still is in my mind and it still worries me that
when you are suddenly diagnosed with cancer and you are so
shocked and you have to undergo major surgery it is really,
really hard, it‘s really a shock and the things that happened in
the hospital just were unfortunate. I am a trained nurse be it a
long time ago and maybe the nurse in me knows too much, but
I felt that many of things could have been easily remedied
with a little bit of thought ...
Grace is a thirty-two-year-old single female who was born in Australia. First
contact was made with Grace early in December, 2007. She initially made contact
via the study webpage after seeing the advertisement in her local newspaper. An
information package was sent to her and she returned a signed consent form to
phone her to arrange a meeting. The interview was held on December 19, 2007.
The initial meeting with Grace was quite different from those with many of
the other participants. Grace was very happy to see me, smiling broadly and
speaking quickly. She immediately began recalling incidents that had occurred to
her over the years, even before we had sat down. From this brief exchange of
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123
information it was apparent that Grace has experienced a number of events. She
indicated that she has had multiple admissions and interactions with the health care
system, both in Queensland and New South Wales since her childhood. After
approximately ten minutes, we settled on a sofa with a cup of coffee and began the
interview. The incident that Grace wanted to share had occurred ten years
previously. The significance of this event and the effect that it has had on her is
apparent throughout her narrative. The transcription of this interview was
particularly difficult because of the speed of the Grace‘s speech. While the length of
the interview was, on average, the same as those conducted with previous
participants (forty-five minutes), the word count of the transcription was almost
double. Despite the complexity and, at times what seemed like multiple issues being
presented, the narrative still revealed thematic considerations in line with other
superordinate themes identified. The only difference was in the emotions identified
in the narrative and from post-interview notes. However, despite these issues, Grace
had an important story to share.
(Grace)... I couldn‘t understand how this simple procedure
had gone so awry and I wanted it to be spoken about and for
somebody to know that this is happening because this was a
very respected surgeon, this Doctor X was and is probably
still so and I was concerned how that could happen under
his care and I felt like a guinea pig see and I actually felt
like a guinea pig, I thought what were they actually doing
where they experimenting with something, what were they
doing so I thought how could they get it so wrong...
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124
The stories of Madeline, Katherine, Jonathon, and Samuel included very
similar issues to those presented by Mia and Grace.
4.4. COGNITIVE AND PHYSIOLOGICAL INFLUENCES
4.4.1. Primary Appraisal
The previous section presented the actual events that precipitated the
participant‘s complaint. The cognitive emotive process, as presented by Lazarus
(1993), asserts that when one is faced with a situation that has been cognitively
assessed by the individual as being against what they expected, this event may
challenge one‘s coping capabilities. It is how the individual responds to that event or
situation that is determined in the primary appraisal phase where one begins to think
about how this situation or event will actually affect them.
Figure 6: Cognitive Appraisal—Primary Appraisal Process
A significant theme that appeared to trigger many of the complaints was
the feeling of being disrespected. It was this sense of disrespect that then fuelled
the expression of emotions, such as anger and anxiety. Heightened emotions
impacted the participants‘ responses. Examples of these expressions of
disrespect are evident in the following data:
Situation/
Event
Primary
Appraisal We think about the
situation/event and
how it will affect us
Secondary
Appraisal
Appraisal
Outcome
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125
(Nick)... I felt like a lab animal, like an experimental
subject, I felt like they had no concern for me as a person or
the injury that I was suffering from...
(Emma) ... made me feel like I wasting a bed and that made
me feel like there was nothing wrong with me and that I
must be putting this on so that is not a good feeling to
have...
(William)... I still can‘t believe what happened and how
little help we received and the lies that were said to cover
up their mistakes...
(Michael)... I was in fact kicked out of the hospital...
(Jonathon)...Why weren‘t they helping me? Do I need to
die in front of them...?
(Katherine)... I felt like I was out of sight out of mind, I
was in the back room I hated it, I was so alone, I just felt
forgotten most of the time...there was no-one to talk to...the
pain just got worse...
The other significant appraisal that was made by participants was the
reaction of sheer disbelief, and shock. This group of participants tended not to
react immediately, but ruminated on the issue for days, weeks and, in some
cases, years before they could act on the issue of discussing the complaint. The
following extracts clearly reflect individuals who were unsure how to react at the
time of the crisis.
(Zoey)... I was leaning against the wall having contractions
and trying to do my breathing I was obviously distressed
people walking past and in the offices and other staff
walking past then I thought is I am standing there right in
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126
front of them, then they would see me, but they just left me
standing for one and half to two hours...
(Andrea)... In the beginning I couldn‘t talk about it without
bursting into tears. I didn‘t complain earlier because I was
too distraught from the experience...
(Grace)... I just couldn‘t believe that happened, such a
basic surgery it was suppose to be more precise surgery and
they actually completely did the wrong thing and I couldn‘t
understand how that could happen so I was in shock and I
couldn‘t believe that it happened...
While the appraisal process for the previous participants reflected different
reactions, they all mirrored the same initial action of resignation and did not voice
their complaint at the time of the event.
4.5. FLIGHT OR FIGHT
4.5.1. Secondary Appraisal
The cognitive processes that occur at the time of primary and secondary
appraisal are often difficult to distinguish. This view is also consistent with
understanding this process from a Heideggerian perspective. As stated by Lazarus
(1991a, p. 357) ‗although people can think reflectively or conceptually, the process
of contextual knowing ... is effortless and nonreflective and stems from merely
―being in the situation‖‘. However, there are some different triggers in these stages
that can allow for the understanding of the analysis process to occur.
As stated previously during primary appraisal one begins to think about how
a situation or event will actually affect them, as where in secondary appraisal, we
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127
ask questions, such as: What do I do? How do I react? Why? When do I react? Are
there any other alternative actions? What are the consequences of such actions? The
best coping mechanisms are chosen by the individual after the questions above are
considered and weighed up as to the best outcome for that immediate situation and
for that individual (Frijda, 1986; Lazarus & Folkman 1984; Lazarus, 1991, 1991a).
Figure 7: Cognitive Appraisal—Secondary Appraisal Process
Of the sixteen participants, only one participant spoke up at the time that
the issue occurred. Samuel, a seventy six-year-old male first made contact by
telephone and requested that an information package be sent to him. The following
week a signed consent form and approval to contact him to organise the interview
was given. Samuel resides in a retirement village with his wife who requires
substantial nursing care. Samuel also has several health issues that have required
multiple admissions to his local hospital. Samuel spoke at length of his previous
career and took great delight in showing photographs and certifications of
commendation that he has received over the years. Samuel had a lifelong career in
Situation/
Event
Primary
Appraisal
Secondary
Appraisal We determine how we
will cope or respond to
the situation/event
Appraisal
Outcome
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128
the protective services and made the suggestion quite early that he has very high
expectations of people who are providing a service.
(Samuel)... I don't suffer fools lightly...the management don‘t
frighten me a bit, not this fella...
(Samuel)... The time before this last time I had an issue I
went and found the complaints lady and I told her all about
my concerns with the staff...she sat there and listened to me
but that was it...
(Samuel)... I was packed up so quickly, I didn‘t realise that the
cannula for the IV was still in my arm, if I did they would
have known about it right then...
Despite Samuel‘s confidence and his capacity to respond at the time of the
issue, he still expressed a concern that based on his previous experiences, he
wasn‘t confident that the issue would be dealt with appropriately. Samuel did
comment that his previous occupation prepared him to be... not scared of
anyone.... and he did recognise that, even with this type of approach, he doesn‘t
always get a resolution ...they fight you all the way...
Another interesting response was that some of the participants had wished,
in hindsight, they had had reacted differently. Nick was a good example of this
observation. This response came from the question ―Can you tell me about your
personality‖?
(Nick)... I‘m not a person that suffers in silence if someone
does something to upset me I make it, make it known as soon
as I can and in most cases immediately. I have a tendency to
speak possibly before I think a bit but I‘m a firm believer in if
Chapter 4: Findings
129
you don‘t tell someone they are doing something wrong they
don‘t know they are doing it wrong and they will carry on
doing it because they think what they are doing is right and it
isn‘t . I think if people take my comments in a constructive
way then it will be okay, I think there is nothing worse than
getting into a situation where you get really upset about
something where you have a valid reason for making a
complaint and then you don‘t make a complaint for whatever
reason then you whinge about it later to somebody else...
Despite such a strong reflection about how he perceived himself, at the time
of the issue that he shared for this study Nick did not react in the way that he
expected he would.
While the remainder of the participants all eventually made a complaint it
was after the fact; and, in some cases, it was days, weeks, months, or years after the
initial event had occurred.
4.6. COPING STRATEGIES AND THE EXPERIENCE OF EMOTION
4.6.1. Appraisal Outcome
Lazarus (1991, 1991a) suggests that having an understanding of our
emotions while we are in stressful situations will influence how we respond and
cope in those situation.
Overall, it would appear that all the participants with the exception of
Samuel, engaged in reappraisal process and responded not as was expected in
relation to the emotions that were identified in their narratives
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130
Figure 8: Cognitive Appraisal—Appraisal Outcome
The following findings were identified by using the emotions matrix to
assign an emotional context to the participants‘ narratives. The emotions identified
were then added up to identify the number of emotions identified by participants
and averages were made accordingly. Table 19 presented in Appendix K reveals all
of the emotion data identified in the participants‘ narratives. Following on from that
table, an overview of the emotions identified is presented.
4.6.2. Examination of Themes with Leximancer Software
As part of the interpretative aspect of this study and to assist with the
validation process, data analysis software was used in place of ―other
researchers‖. The description and use of this software was introduced in Chapter
3. Essentially, the concept mapping view enabled rapid and easy identification of
themes that supported the manual process of coding.
For example, very clear thematic clustering was identified when the text
was analysed via the Leximancer™ software for the narrative of Isabella and
Michael. There were three intersecting themes all revealing similar significance
Situation/
Event
Primary
Appraisal
Secondary
Appraisal
Appraisal
Outcome Emotion
Coping Strategy
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131
in terms of the richness of the findings identified via the manual data analysis
process. The largest theme identified reflected the word information and the
interpretation of this supported the type of communication exchanges that were
occurring. The next significant theme was clustered around the concept of the
word participant. What is interesting here is the obvious tone of the interview,
where the participants were constantly asking and looking for help.
Figure 9: Leximancer Concept Map for Michael and Isabella
They were constantly trying to be heard. They wrote letters, they talked
to anyone who would listen to them, and they found that they were getting no
resolution. Time simply drifted by, and this is evident right in the middle of the
intersecting themes where the concept of weeks and months are presented. The
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132
third significant thematic cluster revolved around the concept of hospital.
Essentially this schematic representation revealed that the narrative is rich in
findings, reflecting the participants trying to raise their concerns about an issue
that occurred in a hospital but not being listened to.
The emerging themes identified from the narrative of Isabella and
Michael— by coding the narrative and the use of the Leximancer data analysis
software — were representative of the superordinate themes that emerged across
all of the participants. Further examples of the Leximancer data views have been
included in Appendix J.
The other significant factor that has added to the thematic analysis and the
interpretation of the sub and superordinate themes has been the identification of the
emotions that were identified in the participants‘ narratives. A checklist was adapted
from Table 5, Emotions Table. Each time an emotion was identified in accordance
with the definitions provided in Table 5, the voice characteristics evident in the
recording and personal journal reflections made by the researcher immediately after
the interview the checklist was marked. When the narrative was completed, each
emotion and the assigned check marks were counted to achieve a final number. For
the purposes of providing an overview of all the emotions identified by participant
and as a group Table 19, Group and Participant Findings of Emotions Data were
developed. This table is available for viewing in Appendix K.
The combined participant emotional thematic summary indicated that
anxiety and anger were the dominant emotional expressions identified across all of
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133
the narratives. The significance of these findings will be discussed further in
Chapter 5. The two emotions not identified in any of the sixteen narratives were the
emotions of jealousy and envy. While the group findings presented in Table 19
present the actual findings in terms of raw data the pie chart in Appendix L depicts
the percentage of the emotions via a pictorial view to illustrate the range from most
dominant to least dominant emotions across all of the participants.
Chapter 4: Findings
134
Table 17: Summary of Participants and Findings
4.7. SUMMARY—PARTICIPANT COMPLAINTS, EMERGING SUB-THEMES, & SUPERORDINATE THEME STATEMENTS
Pt G A Primary Complaint/s Emerging Sub-Themes from Narratives Superordinate Theme Statements
01 Pt M 57 NICK
Treated very rudely by radiographer Poor communication
Treated as a test subject, not as an
individual
Where is their duty of care?
No information about complaints
system, had to work it out on his own
Ineffective communication
Treated with disrespect
Standards of care are not
consistent/Treatment issues
Information about how to make a
complaint is not clear
Anxiety & anger identified
02 Pt F 24 ISABELLA
Suffered post-partum depression,
hospital and child services removed
baby from her custody whilst she was
in hospital
No-one to tell you what to do
I was treated very badly
No-one is listening
Ineffective communication
Treated with disrespect
Standards of care are not
consistent/Treatment issues
Information about how to make a
complaint is not clear
Anxiety & anger identified
03 A M 58 MICHAEL–(Advocate)
Required to act as an advocate for
CSPOO2 as he is her primary carer,
but also had trouble navigating the
complaints system
Having to fight to be heard
No-one cares
Too hard
Ineffective communication
Treated with disrespect
Standards of care are not
consistent/Treatment issues
Information about how to make a
complaint is not clear
Anxiety & anger identified
04 Pt F 69 MIA
Complaint about deterioration in
nursing standards
Poor post-operative care
Poor standard of care
No-one to identify as being in charge
to tell that you are unhappy with care
No information on who to speak to
Ineffective communication
Treated with disrespect
Standards of care are not
consistent/Treatment issues
Chapter 4: Findings
135
4.7. SUMMARY—PARTICIPANT COMPLAINTS, EMERGING SUB-THEMES, & SUPERORDINATE THEME STATEMENTS
Pt G A Primary Complaint/s Emerging Sub-Themes from Narratives Superordinate Theme Statements
Information about how to make a
complaint is not clear
Anxiety & anger identified
05 Pt F 32 GRACE Surgical procedure wrongly performed
How could they get it so wrong?
I had to find my voice and stand up
and get people to listen to me
I worked through the system and by
trial and error I got different people to
listen to me
Ineffective communication
Treated with disrespect
Standards of care are not
consistent/Treatment issues
Information about how to make a
complaint is not clear
Anxiety & anger identified
06 A M 78 WILLIAM –(Advocate) Re: his wife who died
Blames nurse for not making stress
test appointment for wife to attend;
Wife was discharged and died at
home in the middle of the night
I had to work it out, I spoke to
everyone who would listen
Standard of care provided was not
right
I was sent from pillar to post, I spoke
to anyone who would listen because
no-one offered to listen me
Ineffective communication
Treated with disrespect
Standards of care are not
consistent/Treatment issues
Information about how to make a
complaint is not clear
Perception of negligence
Anxiety & anger identified
07 A F 50 AUDREY–(Advocate) Re: her father who died in hospital,
complaint about mgt of father‘s care
being poor.
Father was misdiagnosed
Poor pain management
Father was in the wrong part of the
hospital, he wasn‘t getting the care
he should have been
I wasn‘t being listened to, they didn‘t
follow up my father‘s history
Different nurses every day, they
didn‘t look for anything
No consistency in care
No information
So many issues went wrong
Ineffective communication
Treated with disrespect
Standards of care are not
consistent/Treatment issues
Information about how to make a
complaint is not clear
Perception of negligence
Anxiety & anger identified
Chapter 4: Findings
136
4.7. SUMMARY—PARTICIPANT COMPLAINTS, EMERGING SUB-THEMES, & SUPERORDINATE THEME STATEMENTS
Pt G A Primary Complaint/s Emerging Sub-Themes from Narratives Superordinate Theme Statements
08 Pt F 42 MADELINE Lack of compassion by medical
staff when diagnosed with a breast
lump, then after undergoing a
mastectomy everything just went
wrong
I didn‘t get any clear information
from my doctor
I was so fearful and scared and I
didn‘t feel as anyone cared, I needed
someone to talk to
Ineffective communication
Treated with disrespect
Standards of care are not
consistent/Treatment issues
Information about how to make a
complaint is not clear
Anxiety & anger identified
09 Pt F 30 ANDREA Baby delivered by caesarean section
without proper consent, no clinical
evidence other than the a doctor
making the decision
Suffering from post-traumatic
stress as a result of the Caesarean
section
No information about how to
complain, took me about 12 months to
get my complaint heard
I told the nurses that I didn‘t want it
done, the midwife wasn‘t hearing me
Ineffective communication
Treated with disrespect
Standards of care are not
consistent/Treatment issues
Information about how to make a
complaint is not clear
Perception of negligence
Anxiety & anger identified
10 Pt F 31 CHARLOTTE Misdiagnosis
Suffering from acute appendicitis
while being pregnant
There were no standard procedures
carried out
I didn‘t know which way to go to
make a complaint, I relied on my
friends
Ineffective communication
Treated with disrespect
Standards of care are not
consistent/Treatment issues
Information about how to make a
complaint is not clear
Perception of negligence
Anxiety & anger identified
11 Pt F 54 KATHERINE Very poor pain management
following knee replacement
I would have been better off in a
public hospital
Tucked away in a private room and
Ineffective communication
Treated with disrespect
Standards of care are not
Chapter 4: Findings
137
4.7. SUMMARY—PARTICIPANT COMPLAINTS, EMERGING SUB-THEMES, & SUPERORDINATE THEME STATEMENTS
Pt G A Primary Complaint/s Emerging Sub-Themes from Narratives Superordinate Theme Statements
left to my own devices.
I had to ask for pain relief, no-one
really cared enough to listen
consistent/Treatment issues
Information about how to make a
complaint is not clear
Anxiety & anger identified
12 Pt F 48 EMMA Treated poorly by variety of staff,
particularly by radiology staff
Specialist attitude was very poor
Not good customer service, very short
and very rushed
Didn‘t care that I was in pain
Fired all these questions at me, not
prepared to listen
Ineffective communication
Treated with disrespect
Standards of care are not
consistent/Treatment issues
Information about how to make a
complaint is not clear
Anxiety & anger identified
13 Pt M 36 JONATHON Poor management of suspected
myocardial infarction
Took too long to get specialist
care, I had to go to a private
hospital to get full treatment
I was left with no explanation.
I just wanted someone to tell me what
was going on and how they were
going to help me
I wasn‘t receiving the attention or care
that I should, my family had to make
such a fuss
Ineffective communication
Treated with disrespect
Standards of care are not
consistent/Treatment issues
Information about how to make a
complaint is not clear
Anxiety & anger identified
14 Pt M 74 SAMUEL Discharged with an intravenous
cannula still in his arm
Has had multiple admissions to
hospital and has been consistently
upset with the care he has received
Not the same sort of care that you
received from nurses years ago
Who is in charge? you don‘t know
who it is anymore
Treated as a complainer
Ineffective communication
Treated with disrespect
Standards of care are not
consistent/Treatment issues
Information about how to make a
complaint is not clear
Perception of negligence
Anxiety & anger identified
Chapter 4: Findings
138
4.7. SUMMARY—PARTICIPANT COMPLAINTS, EMERGING SUB-THEMES, & SUPERORDINATE THEME STATEMENTS
Pt G A Primary Complaint/s Emerging Sub-Themes from Narratives Superordinate Theme Statements
15 Pt F 76 AVA Did not receive proper
rehabilitation, like physio after I
had my hip replacement
I felt like I was a nuisance
Nurses were too busy
It was hard to get information about
what was happening to me.
Ineffective communication
Treated with disrespect
Standards of care are not
consistent/Treatment issues
Information about how to make a
complaint is not clear
Anxiety & anger identified
16 Pt F 36 ZOEY Labour mismanaged, resulted in
emergency Caesarean section,
stillborn child
I wanted someone to believe I was in
labour, they acted as if they are the
only ones that know what is going on,
they just didn‘t listen
No confidence in graduate nurses,
where are the staff with experience?
Ineffective communication
Treated with disrespect
Standards of care are not
consistent/Treatment issues
Information about how to make a
complaint is not clear
Perception of negligence
Anxiety & anger identified
Chapter 5: Key Themes and Discussion
139
Chapter 5: Examination of Key Themes and
Discussion
5. INTRODUCTION
This chapter provides a synthesis of the findings, the interpretations, the
conceptual framework, and literature used to understand the lived experience of
patients who have made complaints. Through exploring and trying to understand
the lived experience of those patients who have actually gone through the
process of making a complaint, a series of themes has been identified that has
the potential to address those issues that have triggered dissatisfaction. The five
key themes are:
Ineffective Communication
Treated with Disrespect
Standard of Care is Not Acceptable
Information on How to Make a Complaint is Not Clear
Perceptions of Negligence
―Our complaints are like arrows shot up into the air at no target:
and with no purpose they only fall back upon our own heads and
destroy ourselves‖ Sir William Temple (1628-1699).
Chapter 5: Key Themes and Discussion
140
5.1. SOURCES OF MEANINGS
The opportunity to gain some understanding of what it meant to the
patient to engage in the process of lodging a complaint, to identify what issues
precipitated the complaint, to understand the actual experience of making a
complaint, and to understand the subsequent experiences and the associated
emotions following lodging the complaint, were all clearly evident in the themes
and insights that emerged from the interviews. The following key themes have
been captured to illustrate opportunities for service delivery improvement in the
area of handling complaints.
5.1.1. Theme 1: Ineffective Communication
Overall the most significant theme that emerged from the narratives was
the issue of the participants feeling that they were not being listened to.
Appendix M provides further extracts identified in the narratives that reflect how
the theme of ineffective communication was interpreted. Examples of some
statements that were explicated from the narratives reflecting this theme are:
(Audrey)... There was a lack of communication...
(Grace)...The doctors are dealing with a different person
every two seconds, they‘ve got that next person, different
case, different client, different whole person and they have
got to cut through all of that, still be personable and get to
what the issue is and that‘s a difficult thing to do. So, I
really think there needs to be an issue of them
acknowledging their patients at the beginning type of thing,
and what are we here for and also giving them clear
Chapter 5: Key Themes and Discussion
141
directions. I know that is really difficult to say but because
it takes energy and they often don‘t have the energy to do
that because their brain space is consumed with taking care
of what blood you needed for that last patient, they may be
going into surgery in an hour but they still have ten other
patients before they go there and you know how do I not
know that may have happened with my surgery. You know
I believe that a lot of complaints out there are just
miscommunication and I think that's what most of it is, I
hear a lot of my friends complain about this that and the
other about what has happened to them and they haven't
told the right people...
(William)... She went off without speaking to me...
(Mia) ...On numerous occasions a nurse would come in and
say hi, I‘m Marj, and I will be looking after you, and you
would rarely see them again. I am aware of the huge
changes in nursing but there seems to be such emphasis on
the technical side and such a lack of compassionate bed side
manners and understanding on the nursing side. A smile, a
few kind words and an attempt to make the patient
comfortable are not too much to expect. Emotionally the
patient needs and requires these things to stay focused and
positive...
(Andrea)... I kept saying to the midwife I don‘t want this,
this is not what I want to happen and so on, the other thing
was that my son was taken away because they said it was
routine practice so he was taken away with my husband and
the midwife apparently said to my husband oh I am so
worried about your wife, she is so distraught about having
Chapter 5: Key Themes and Discussion
142
the Caesarean but no-one actually never said anything to me
at all...
(Charlotte)...they never listened...
In the study conducted by Daniel, Burn, and Horarik (1999) where 290
people were surveyed who had lodged a complaint with the New South Wales
Health Care Complaints Commission, 22% of all the complaints were related to
poor communication and rudeness. The study conducted by Friele and Sluijs (2006)
of 424 patients representing 74 hospitals in the Netherlands revealed that only 9% of
their respondents cited a communication issue as being the catalyst for the
complaint. There is a greater synergy between this study and the study conducted in
New South Wales than with the study conducted in the Netherlands.
A deeply concerning factor from an analysis of the literature is that the issue
of ineffective communication has certainly been identified repeatedly over the last
two decades as a major contributing factor to patients making complaints. In 2001,
Anderson et al., after completing a retrospective study over a 30-month period of
patients at a major Australian hospital, stated that 57% of the 1,308 complaints
investigated were related to poor communication or to the treatment provided. This
study presents both of these themes as separate issues. So, while there is insufficient
evidence to confirm how much of the 57% concerned communication and how
much was related to treatment issues, the significant factor here is that, a decade
later, these issues are still the most prominent factors related to complaints.
A study conducted in New South Wales in 2008 by Garrett et al., identified
issues associated with communication problems and the levels of dissatisfaction
Chapter 5: Key Themes and Discussion
143
experienced by the patients they studied. However, the participants involved in that
study were all identified as ―migrants‖ with English as a second language. The
recognition of not having any participants in this study from a non Anglo Saxon
background has been acknowledged in the limitations that will presented later in
chapter 6. Despite not having this representation, one could postulate, based on this
research that the issue of language significantly influences the way we
communicate. Based on the findings of this study it has been confirmed that health
care staff communicated poorly with patients who actually spoke the same
language—this issue must be considered as being even more applicable to patients
from culturally and linguistically diverse backgrounds.
Another significant factor that should be considered along with these
findings is that of the emotional responses of anger and anxiety and their influence
on communication. These emotions have been clearly linked to communication
breakdowns, as messages are not relayed appropriately; and, in many circumstances,
mixed messages occur, both in relaying and interpreting (Lazarus, 1993). As
discussed in Chapter 1, as part of the interpretative endeavour of this study, Lazarus‘
Cognitive-Emotive Model of Coping with Situational Challenge was used to
provide a contextual understanding of the emotions discussed by the study
participants. To reiterate, cognitive appraisal theory can best be understood in the
context that when an individual experiences an event, this event then usually
becomes the catalyst for the individual to think about how this event will affect
them. The individual then proceeds with determining or appraising how they
Chapter 5: Key Themes and Discussion
144
perceive that they will respond or cope with that given event or situation. The final
step of this process will determine how that individual will behave or respond. This
outcome is dependent upon what emotions the individual has experienced as a
consequence of that specific event or situation. While this process is described as a
series of well defined steps, the actual process is much more fluid (Lazarus, (1993);
Stephens and Gwinner, (1998: and Watson & Spence (2007). This non-linear
process was definitely apparent in the narratives of many of the participants. Many
of the participants did not react as they normally would have if they were consumers
in a non-hospital setting.
To explore this further all of the participants were asked to describe their
own personalities, and whether they perceived themselves as being capable of
complaining at the point of having the experience of dissatisfaction. The participants
who viewed themselves as having assertive personalities, whereby they felt that they
would not tolerate any perceived indiscretions being perpetrated against them, did
not respond in this manner while being inpatients. The majority of the participants
in this study revealed that their personalities were more on the reticent side but they
also revealed the transformations or awakenings that occurred that enabled them to
voice their complaints, despite it being out of character.
When we explore Lazarus‘s cognitive appraisal theory, we can see that it
reflects the ways in which human beings cope with life challenges and stresses.
When we are in a position of control and have known expectations, we tend to
respond and behave as per our previous behavioural responses. However, when
Chapter 5: Key Themes and Discussion
145
certain emotions, such as anger and anxiety emerge the cognitive appraisal
process of the situation changes (Lazarus, 1991; Stephens & Gwinner, 1998;
Watson & Spence, 2007). Audrey encapsulated this observation as the following
dialogue illustrates. It reveals the build up she went through. While she started
off by very carefully explaining the pros and cons of complaining, when the
emotional responses of anger and anxiety started to infiltrate her words, the more
her personality began to change. She clearly wanted to be perceived as being
polite and understanding, yet she knew that in order to have her concerns heard
she would have to step out of her comfort zone and communicate differently:
(Audrey)... My personality is a funny one really because I
guess if I look at this situation with my dad part of me was
always thinking are they doing the best they can, so I was
always like the speech pathologist she was a lovely young
girl so I was I didn‘t want to come across as complaining to
her you know it‘s like moaning at the bank clerk about the
bank fees it‘s not their fault you know what I mean so there
would have been a part of that in it because I was very
emotionally attached to this as most people would be when
you have someone in hospital. I would try and be a little
patient, I don‘t complain easily but if I am not careful I can
get quite aggro if I think things are not getting done so I
tried to sort of restrain myself a bit. I remember one time I
was there and the doctor, first of all he didn‘t want to give
me any information because he wasn‘t dad‘s doctor and he
is flicking through and I wanted to get really I almost felt
that I wanted to get a bit rude to him, you know there were
times I felt like saying do I have idiot plastered across my
Chapter 5: Key Themes and Discussion
146
forehead that you guys are just withholding information or
whatever I‘m not really sure but I also wanted to come
across as polite too so I‘m not one of these that you know
would rant and rave sort of thing but I would have to say
that I jumped up more than I ever done, really and truly
more than I have ever done because I was very concerned
that dad was going to die...
This example clearly identifies how emotions can influence behaviour.
5.1.2. Theme 2: Treated with Disrespect
The second theme that emerged from the narratives was a sense that the
participants were made to feel insignificant and, on many occasions, felt that
they were being treated with disrespect, as the following extracts reveal:
(Nick)...I walked in the door it was almost like I was an
experimental object they talked over me, they talked around
me the only thing they didn‘t do was actually talk to me
there was no explanation of what I was there for or they
read my referral and read that I had pain in my shoulder, but
there was no interaction with me as a subject..
(Charlotte)... I was flat out trying to walk, they just
watched me shuffle out, holding my abdomen, no shoes, in
my pyjamas and I didn‘t have a bra on and I was half way
through my pregnancy they just stood there and watch me
shuffle out without anyone helping I just felt, I felt like crap
I did I thought a dog would be treated better than this...
(Isabella)...Nurse M with her attitude and they reckon that
there is nothing wrong with it, well Nurse M said to two
people, Government officials that people who have a mental
Chapter 5: Key Themes and Discussion
147
illness or a disability should not have children and that‘s her
attitude that they should be removed...
(Emma)… I was obviously in great pain but there did not
seem to be any consideration for that and when the Doctor
was pushing me, it just felt like a blunt drill trying to come
through the back of my head, I just felt where is your
compassion, you know...
(Charlotte)…I think to me things would have been a lot
better had he been a bit more of a hands on doctor that to
me would be it in a nutshell I didn‘t expect him to be able to
operate on me or do anything like that, he simply came
across as someone who I was wasting his time and that was
really upsetting and especially when I felt like he knew who
I was and you know he was familiar with me. I felt as
though I was treated, I don‘t know like a real dreg of society
and that was really humiliating as well...
(Jonathon)… I find he is just looking at me as if I am an
idiot I don‘t have a medical degree so I must not know
anything it is really insulting really to my intelligence. I am
not claiming to be the smartest person in the world but I am
certainly not an idiot...
Appendix N provides further extracts, identified in the narratives that
reflect how the theme of being treated with disrespect was interpreted. This issue
has certainly been identified in other studies, but perhaps not as directly as it has
in this research. Finney Lamb et al. (2008) reported that the women who were
involved in their study stated that they feared not being taken seriously if they
made a complaint. This could be interpreted as the women not feeling that the
Chapter 5: Key Themes and Discussion
148
staff would respect them. The other issue that can be raised here is that while
that study only reported on women, this research included representation from
the males in the study who also reported that they had been treated with
disrespect. From this finding, it could be proposed that the issue of feeling
disrespected is not gender biased. However, further research would be required
in order to confirm this assumption.
(Samuel)... Treated as a complainer...
(Jonathon)... Is anyone going to pay attention to me...?
(Nick)... I found it extremely degrading...
This theme of being disrespected has, in previous studies been combined
with other issues, such as communication difficulties. These studies were
predominately conducted in the earlier part of this decade, as presented in
section 2.5.1. Other Australian studies reviewed did not identify this issue as a
stand-alone theme. Recent international studies that have featured the experience
of feeling disrespected as their central focus were undertaken in England and
Sweden. Cocozza Martins (2008) and Wessel, Helgesson and Lynöe (2009)
studied a marginalised group of patients that represented the homeless
community in their respective countries. In both of those studies, participants
reported that their strongest objection to health care staff treating them
disrespectfully was directly linked to the hospital staff not accepting the social
norms of the homeless people and wanting them to conform to their own
standards. This interpretation of being treated with disrespect in the context of
Chapter 5: Key Themes and Discussion
149
social norms has parallels with the previous international findings. However, the
difficulty that presents itself in a country like Australia is actually establishing
what acceptable and unacceptable social norms are.
Beach, Sugarman, Johnson, Arbelaez, Duggan, and Cooper (2005)
confirmed that the underlying premise of being treated with dignity was clearly
linked with the patients they reviewed as having reportable positive outcomes.
Examples such as having patients directly involved in the decision-making
surrounding their care, promoting patient autonomy was a way that patients were
able to tangibly reflect that they felt they were being treated with dignity. This
research identified similar themes of not being listened to, not being consulted,
or staff doing things without their consent, all supporting the previous study
findings identified by Beach et al. (2005).
5.1.3. Theme 3: Standards of Care Are Not Consistent
A variety of studies have reported that patients have many reasons for
making complaints. From an Australian perspective, Taylor, Wolfe and Cameron
(2004) confirm this assertion based on patient‘s complaints that had been compiled
from 67 Victorian hospitals over a 5 year period. Rodgers, Karlsen, and Addington-
Hall (2000) suggest that it is in the interaction between staff and patients that issues
tend to occur. This is a dilemma, since the patient/health care provider relationship
is based on the human aspect. Rodgers et al. (2000) suggest that patients become
dissatisfied with care delivery if their needs are not being met, or if they perceive
that staff are not providing adequate care.
Chapter 5: Key Themes and Discussion
150
This perception was clearly identified in the narratives of this research. Each
participant made reference to the standards of care not being appropriate, consistent,
or adequately meeting their needs in some respect. Appendix O provides further
extracts identified in the narratives that reflect how the standards of care were
perceived as not being consistent. For example:
(Isabella)... I‘m going on there is something wrong, please
someone give us a hand…
(Andrea)...I felt that I saw a different nurse every day so
that no-one really knew or cared in my opinion how I was...
...Quite a shock to me to see the deterioration in the nursing
standards and to realise that there is a need for improvement
in some areas...
(Samuel)... I don‘t really think they care, I really think that
they are just stuck in their work practices...
(Mia)...I was unfortunate to have several young graduates
attending me that they did not give me any confidence that
they knew what they were doing. One graduate nurse was
teaching the other how to aspirate my Ryles tube; another
graduate nurse washed me with cold wipes whilst I
shivered...
(Michael)...You at least think that you will get people to do
their job at the minimum...
(Audrey)... The reply I got was we can‘t do anything about
getting him out of bed he has to be assessed by a rehab
person, I think he had been in hospital about three days then
and so for Dad at his age that‘s too long to be just sitting
Chapter 5: Key Themes and Discussion
151
and lying in a bed and we came across issues where Dad
was a very very thin man and there was no curtains on his
windows, he had a room of his own because he had they use
to say he got a bug in his lung, but he had, had it there for
years but it always meant that he went into isolation and we
couldn‘t provide anything like a hot water bottle or to try to
work out ways to keep him warm he use to get very cold but
he couldn‘t have too many blankets on his bed because it
affected the arthritis in his feet...
(Zoey)...My husband was sent out of the room and I was
just like told to lay down, we just really thought something
must be really wrong when you are in a situation like that I
was fully dilated just in transitional contractions I couldn‘t
really sort of sit up and go hey let‘s talk about this. We just
thought that something must be really wrong and when my
husband was sent out then I was sort of yeah, then all I
wanted to do was get up on the trolley and they kept saying
I had to lie down and I was having a really intense back
labour and the midwife kept putting her hand on my chest
and saying no you have to lie down, you will fall off the
trolley...
Reflecting on the QAHCS findings reported in 1995, a clear message is
that the same adverse events that led to complaints being lodged then are still
being reported today. While this research is not able to identify significant
numbers of adverse events, the narratives provide rich sources of data that
confirm that patients are still dissatisfied with the service they are receiving
today.
Chapter 5: Key Themes and Discussion
152
5.1.4. Theme 4: How to Make a Complaint is Not Clearly Evident
A variety of studies conducted over the last decade confirm the value of an
effective complaints handling system. The findings presented by Romios et al.
(2003) Draper and Hill, (1995), and Draper (1997) all confirm that understanding
and addressing patient complaints leads to improved clinical outcomes. More recent
studies, such as those undertaken by Stiller et al. (2009), and Taylor et al. (2004,
2002) identify important statistical information concerning complaint numbers per
admissions, as well as overall satisfaction with service delivery. By responding to
identified issues this type of data has the potential to influence organisational
improvements. The platform for the relevance that the identification of complaints
can have is indeed evident. With this identification one could propose that the
participants involved in this research provided clear understanding about their
interaction with the complaints system. Unfortunately, this was not the case.
Certain issues repeated through all of the participant's narratives were the
gaps between what the participants wanted and needed in terms of support and what
they actually received. None of the participants voiced any feelings of satisfaction
with engaging in the complaints system. Most reported a sense of having to work
through a complex system that was not readily accessible. Appendix P provides
further extracts identified in the narratives that reflect how the theme of how to
make complaint was not clearly evident. For example:
(Nick)...I wasn‘t given any information and nothing about
the hospitals complaints system whatever...
Chapter 5: Key Themes and Discussion
153
(Jonathon)...I was left to figure out what the system was by
myself it eventually did work in my favour because I did
make a complaint by letter and I did receive a resolution to
that complaint but in terms of the complaints handling
process I don‘t know what the process is so I don‘t know if
what I did was actually following the process because no-
one told me what the process was..
(Audrey)... I wasn‘t given any opportunity to vent my
grievance to anybody; no-one actually didn‘t give me the
opportunity to do anything about it...
(Michael)...I just needed to know what was going to
happen, if there was some sort of person who could tell me
this is what is going to happen this is what we are going to
do without Government interference or red tape bullshit and
go this is what is going to happens, and these are your
rights. When Participant 3 was in hospital neither of was
given any information on what to do, I was in fact kicked
out of the hospital...
(Madeline)… I told them I didn‘t complain earlier because
I was too distraught from the experience. So, I‘m yet to
receive anything from them...
(Jonathon)...The complaints system works you until you
run out of any further avenues, they know how much money
you need how long they can push you what it takes, they
don‘t want you to be knowledgeable about the complaints
system, and I have to find another avenue I just have to...
(Samuel)...I didn‘t receive any information of that type and
no-one mentioned anything about how to go about or who
Chapter 5: Key Themes and Discussion
154
to talk to if you were unhappy about anything going on. I
really think that while you are in hospital you should be
given some sort of number to ring if you are unhappy with
something, a lot of people don‘t really know how to express
themselves or what to say and for the hospital‘s benefit too,
if I was a CEO in a hospital I would want to know if
someone was not happy and I think really if they don‘t
know that their patients are unhappy how can they know
how to correct it...
(Charlotte)...I actually didn‘t know anything about the
complaint system of the hospital I had to work it everything
out myself it was only up to me to work it out , chasing
people and finding out information for myself that I was
able to work out what I should do. There was not anybody
there that was prepared to help me and I just had to work
everything out myself...
This outcome clearly reflects the tip of the iceberg (Schwartz and
Overton, 1992) and the pressing urgency to have systems in place that are at the
very least patient friendly and more appropriately patient-centred.
The identification of this theme must be viewed as a significant factor in
improving patient care. A number of past studies support the notion that if
patients lodge complaints, their complaints will be used to drive future quality
initiatives, and thus improve care (Douglas & Harrison, 1996; Anderson et al.,
2001; Ford, 2001; Taylor et al., 2004). If the processes in place to capture these
potential quality initiatives are not suitable or accessible to patients, one can only
imagine how many opportunities for improvement have been missed.
Chapter 5: Key Themes and Discussion
155
5.1.5. Theme 5: Perception of Negligence
While the perception of negligence was identified as being a superordinate
theme, it was not clearly discernible across all of the narratives as the previous four
themes were. One of the difficulties arose in the interpretation process. At times the
narrative content reflected a variety of thematic representations (mixed messages)
and at times it was difficult to distinguish between the theme of standards of care
not being met and the theme of perception of negligence.
(William)... I received no help, in fact there was one nurse
in particular that I found very difficult and I blame her for
the circumstances surrounding the death of my wife and I
believe that she should be struck off and never be allowed
to work again...
(Audrey)...I said I felt like Dad was eighty-six he had a lot
of health issues and they basically kind of like they were
just happy to have him just slip away I honestly I did. I
battled for everything...
(Andrea)... I had my son delivered by Caesarean section
which at the time we were sort of, it was a rushed situation
and we gave no consent and we were definitely not given
any information in any way, we sort of were just moved
into a room and we thought at the time that something must
have been really wrong and then after it was all sewn up
and everything the doctor came in and said that he felt that I
had been in labour long enough that was his only reason for
the Caesarean...
Chapter 5: Key Themes and Discussion
156
(Zoey)... In the beginning I couldn‘t talk about it without
bursting into tears and I guess I also heard other stories in
the community about the not very good maternity care at
this hospital.
(Katherine)... You know there is saying that says ―doctors
bury their dead, no what is it, and doctors bury their
mistakes‖...
The primary influence in the interpretation process to distinguish the theme
of negligence from anything else was related to the participant‘s involvement with
other agencies. Some of the participants also spoke about legal interactions they had
had, or indicated that they wanted to pursue their complaint further via other
avenues outside the health care system.
As well as identifying the thematic interpretations about complaints
handling through the narratives of the participants, four questions were posed in
Chapter 3 to assist with this interpretation.
5.1.6. Emotions that Precede a Complaint
A question proposed in this study challenged the assumption that anger is
always experienced by patients preceding a complaint being made, as is seen in
non health care settings. The overwhelming response is that it is. Anger was
experienced by every participant in this study. While it was not the primary
emotion identified, it was still evident in all of the participants‘ cognitive
decision process regarding whether to make a complaint or not.
Daniel, Burn, and Horarik (1999) identified that 84% of their participants
experienced anger as a consequence of the incident that they were complaining
Chapter 5: Key Themes and Discussion
157
about. Anxiety was identified in 4% of the participants. Variations between
those results and the findings of this study could be attributed to the
interpretative nature of this research. The respondents of the Daniel, Burn, and
Horarik (1999) study self-reported and recorded the emotional responses that
they experienced at certain points of the complaint process. This factor should be
taken into consideration and included in the potential limitations of this study
and suggests an opportunity for further research, in which participants are more
involved in the hermeneutic process of validating the interpretations of the
researcher. The participants in the Friele and Sluijs (2006) study also identified
emotions such as anger, distress, and anxiety as representative of how they felt
while experiencing the issue that triggered the complaint. However, it only
revealed these emotions as being represented in general terms.
In accordance with Lazarus‘ emotive theory of coping, the identification
of anger as a main driver of complaining behaviour (Lazarus, 1991; Stephens &
Gwinner, 1998; Watson & Spence, 2007) was supported by this research.
Making staff aware of the emotion and its influence on complaining behaviour
may serve to identify issues earlier before the emotion of anger has been fully
realised.
5.1.7. Equity in Complaining
A consideration discussed early in this study was whether patients will
complain at the time of experiencing dissatisfaction. Of the sixteen participants
who shared their experience, only one participant clearly represented this action.
Chapter 5: Key Themes and Discussion
158
This outcome provides some insight into how patients view themselves in terms
of their consumer role with health care. The findings revealed that many of the
participants viewed themselves as being assertive, but this was not reflected by
their behaviour. The findings of this research could indicate that the consumer
within the hospital health care system has not yet been ingrained as a right of
expectation. Perhaps, as stated by Blumenberg (2003, para 3) ―Patients must
learn to become their best advocates for good health care‖ and not just accept
what they receive.
5.1.8. Motivation to Complain
Another question considered was to try to understand whether patients who
actually complain do so because they want to try to improve the situation or whether
there was evidence of other motivations. Before addressing that question, however,
another factor must be considered.
Another important aspect of the cognitive appraisal process in line with
the way we can react, suggests that as individuals, we tend to respond only to an
event or situation if we think that we have some capacity to control the outcome.
Whereas, if through the appraisal process we deem the situation as being totally
out of our control, with minimal opportunity to influence the situation, our
response is usually denial or complete resignation (Peacock & Wong, 1990;
Schoefer & Ennew, 2005). All of the participants in this study indicated that they
wanted to influence change, but they obviously did not feel that they could effect
change at the time of the issue occurring. As only one participant complained at
Chapter 5: Key Themes and Discussion
159
the time of the issue, based on the above insight the remainder of the participants
must have made the appraisal that they could not effect change at that given
moment. Perhaps this outcome explains why the same issues are still being
reported as contributing to patient complaints. If the majority of complaints are
received after the fact, then the impact of understanding the perceived behaviour
is lost on the perpetrator of that negative interaction. When actions are
implemented as a reaction to an identified issue one could question whether the
full impact of the underlying reason for that improvement can be truly taken on
board, at the point of origin where it matters.
5.1.9. Future Admissions
Research into service delivery failures has identified that if a service
provider responds appropriately to a consumer who has expressed some negative
emotions about the service interaction, they are more likely to develop a better
relationship with that customer, and thus retain them as a customer (Bodey &
Grace, 2006; Schoefer & Ennew, 2005). The narratives did not reveal any
definitive responses as to how these patients view their relationship with the
hospital provider or their potential future admissions. The fact that many people
do not have the opportunity to choose alternative health care providers may
partially explain why people do not complain more readily about their health
service; they know that they may have to return to that same service in the
future.
Chapter 5: Key Themes and Discussion
160
While section 5.1.2 clearly identified disrespect as being a key reason for
patient dissatisfaction and the positive impact that being treated with dignity has
on patient outcomes, the findings from this research and other studies provide
further insight. All of the participants in this study reported negative outcomes as
a result of dissatisfaction experienced with their health care. Studies conducted
by Hudak and Wright (2000), and Bova, Fenni, Watrous, Dieckhaus, and
Williams (2006) confirmed that patients who were dissatisfied with their care
were more likely to have delays in their recovery. This outcome affects the
patient in terms of physical outcomes; and, the ongoing effects of delayed
recovery can also have a profound impact on the individual and health system.
5.1.10. Thematic Correlations and Patient-Centred Care
The identification and discussion of the preceding key themes have clear
parallels with the dimensions and concepts that patient-centred care
encompasses. This presents an opportunity to explore the features of patient-
centred care in terms of the themes and insights that emerged from the
interviews. According to a recent discussion paper released in September 2010
by the Australian Commission on Safety and Quality in Healthcare (ACSQHC),
―strategies and policies that promote patient-centred care‖ (p. 37) have the
opportunity to improve quality outcomes throughout the Australian health
system. This paper defines patient-centred care as ―…health care that is
respectful of, and responsive to, the preferences, needs and values of patients
and consumers‖ (ACSQHC, 2010, p. 7). This definition seems to encompass the
Chapter 5: Key Themes and Discussion
161
sentiments expressed by the study participants. A pictorial view (Figure 10) has
been included to illustrate the thematic issues identified and their relationship
with the dimensions of patient-centred care. These issues will be explored
further in Chapter 6 in context with the recommendations that have been
proposed.
Chapter 5: Key Themes and Discussion
162
Figure 10: Thematic Correlations and Patient-Centred Care
(Adapted: Gerteis M, Edgman-Levitan S, Daley J, Delbanco (As cited in: Patient-Centred Care: Improving Quality and Safety by Focusing Care on Patients and Consumers—Discusssion Paper,
2010, p.13)
Dimensions of Patient-Centred Care
Theme 2:
Treated with Disrespect Theme 3:
Standard of Care is Not Acceptable
Theme 1:
Ineffective Communication Theme 4:
Information on How to Make a Complaint is Not Clear
Theme 5:
Perceptions of Negligence
Chapter 6: Conclusion, Limitations, and Recommendations
163
Chapter 6: Conclusion, Limitations, and
Recommendations
6. INTRODUCTION
This study‘s goal was to provide health services with information that
may assist them in the development of service improvements regarding
complaint handling. However, the information that can be gained from a
phenomenological perspective cannot simply be passed on and applied to a
health setting such that the health service will automatically see improvements in
the management of complaints. Evidence emerging from this study will provide
illumination, increase perceptiveness and lead to discussion about what the
experience of complaining meant to a group of people in the health care context.
This concluding chapter returns to the significance of the study and draws links
where appropriate to the findings identified. Major themes emerging around
patient expectations have been used to focus the recommendations. The chapter
will conclude with comments about future research opportunities.
―I think a compliment ought to always precede a complaint, where one is
possible, because it softens resentment and insures for the complaint a
courteous and gentle reception.‖ Mark Twain (1835-1910).
Chapter 6: Conclusion, Limitations, and Recommendations
164
6.1. CONCLUSION
In exploring the experiences of patients who had made a complaint about
some aspect of their inpatient stay in an acute care hospital, this study has revealed a
range of important issues.
The analysis process revealed 5 superordinate themes which were
discussed in Chapters 4 and 5. These themes include: (a) ineffective
communication, (b) treated with disrespect, (c) treatment issues, (d) how to
make a complaint is not clear, and (e) perceptions of negligence. These 5
superordinate themes are the messages that emerged from the narratives of the
participants of this study. As presented in the previous chapter all of the
participants in this study indicated that they wanted to influence change, this
recognition that patients do want to play an active role in improving health care
service delivery needs to be embraced and actively sought. Whilst this study was
guided by a phenomenological perspective representing an interpretative
approach from a Heideggerian perspective, other mechanisms also supported the
emergence of the final themes.
A key tool utilised in this study as part of the ―checking‖cycle was the
use of the data analysis tool called Leximancer™. The outcomes of using this
tool assisted with the thematic interpretations. The ability of the software to
extract significant concepts and then visually represent the relational strengths
between the concepts was very useful and aided the interpretative process. The
most positive contribution of this tool was the relative ease in being able to ‗data
Chapter 6: Conclusion, Limitations, and Recommendations
165
mine‘ a significant amount of text, with the subsequent visual display of clear
results. Another aspect of this study that fits well within the ―Checking‖process
is the identification of the limitations that have emerged from this study.
Two primary questions were posed at the beginning of this study: Firstly,
what can be learnt from patients when they complain, and how can these
findings inform service improvement in hospitals? These questions are
addressed below.
6.2. LEARNING FROM PATIENTS TO INFORM SERVICE
IMPROVEMENT
The findings from this study have identified that the participants had very
clear insights into what they perceive as being good or bad representations of care.
Most individuals have an expectation that they will receive quality care and service
from their health care providers (Hart, 1996; Lundqvist, & Axelsson, 2007; Redfern
& Norman, 1990) however this is not always the case as was evidenced by the
participants from this study. The two primary questions presented above will be
answered by relating the findings of this study to the PDCA model (Figure 1)
introduced in section: 2.5.2., with the goal being to integrate a patient-centred care
approach with the recommendations. Another important aspect of striving for
excellence to achieve patient-centred care should be considered within the principles
of the Australian Charter of Healthcare Rights as was presented in section: 2.6.1.
By applying the findings to answer these two questions (what can be learnt
from patients when they complain, and how can these findings inform service
improvement in hospitals) within the context of the PDCA model has the potential
Chapter 6: Conclusion, Limitations, and Recommendations
166
to provide tangible and constructive opportunities for improvement as part of the
conclusion of this study. The PDCA model represents a continuous cycle (Gilmour
& Hunt, 1998) which would suggest that opportunities to revisit and improve on
processes are inevitable. Figure 1, representing the PDCA cycle has been
reintroduced to assist with the conclusion process.
TQM Framework—Plan, Do, Check, Act Cycle (as presented in Figure 1)
Source: (Lim, 2009).
As figure 1 depicts, the PDCA cycle is composed of four-steps that can be
used as a model for quality improvement. The first two steps in the PDCA cycle
will be used to discuss the significance of why the data for this study was collected
and the significance of what was identified. The final two steps of the cycle will be
used to discuss the outcomes from the contextual framework used to explore the
phenomenon of complaining and the identification of limitations and
recommendations.
Chapter 6: Conclusion, Limitations, and Recommendations
167
6.2.1. Planning
The first-step of the PDCA cycle focuses on deciding what could be
improved and then identifying the data or sources that can help to inform this
process. There are a variety of goals that exist to assist with the planning process. Of
particular importance in terms of this study‘s findings is the identification of
consumer expectations (Gilmour & Hunt, 1998). The assumption is that all service
industries strive to achieve consumer satisfaction (Malthouse, Oakley, Calder, &
Iacobucci, 2003; Vikas, & Kamakura, 2001) and the only way this can be validated
is by the consumers themselves. The findings and themes presented and discussed
in Chapters 4 and 5 have certainly identified a range of opportunities for
improvement.
6.2.2. Doing
The ―Do‖ process of the PDCA cycle is where opportunities for
improvement are usually identified. The collection of information and baseline data
provide insights into how a process is performing. This data are very important as it
is the means of evaluating whether improvements have been achieved in
implemented measures as a result of the initial data identified (Gilmour and Hunt
1998). The baseline data of this study are the narratives collected from the
participants. This baseline information informed the emergence of significant
themes as presented in (6.2). Through the interpretative process significant
opportunities for improvement have been identified from the sub and superordinate
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168
themes. Concluding remarks will be aligned with the superordinate themes that
were identified.
6.2.3. Theme: Ineffective Communication
A significant theme that surfaced from the narratives was that participants
did not feel that they were being listened to, nor supported to voice their concerns or
complaints, as the following extracts reflect:
6.2.3.1. Issue 1: To be Listened to and Supported
(Mia) ...A little bit of support, guidance and encouragement
would help a lot...
(Samuel)...I suppose it will never go back to the olden days
but it would be nice to see the head person come around
every day and say hello, and how are you, which never
happened...
(Katherine)... I look back and I think that I really should
have been more in people‘s faces, that‘s what you have to
do to get people to listen to you...
(Ava)...I just wish someone could have been a lot more
honest to me. I wasn‘t getting information, and I didn‘t
know where to go. I found that really frustrating...
This outcome, reflecting issues with listening and support, would seem at
odds with many communication experts in the health care arena. According to
Arnold & Underman Boggs (2007); Burnard & Gill (2009); Glass (2010); Jonas-
Simpson, Mitchell, Fisher, Jones & Linscot (2006); O‘Toole (2008); Schuster &
Nykolyn (2010); Stein-Parbury (2009); and Tamparo & Wilburta (2008), listening
is a key communication skill required to facilitate quality care. Based on this
Chapter 6: Conclusion, Limitations, and Recommendations
169
evidence, health service providers need to identify and assess their listening
capabilities to ensure they are not missing out on the valuable insights that their
consumers might be able to share with them.
6.2.4. Theme: Treated with Disrespect
For the participants in this study there was a strong sense of wanting to be
believed and acknowledged. They wanted to know that they would be taken
seriously and not disregarded as a ―whinger‖ or a ―complainer‖. The participants
wanted to send a message saying that it is difficult enough to stand up and say that
something is not right in the first instance. Coupling with the ‗perception of a
difficult situation‘ with ‗further negativity‘, can leave the consumer feeling
dismissed and isolated. A fundamental human need that is intrinsically linked with
the desire to be believed and acknowledged can be viewed in the context of esteem.
Maslow (1908—1970), proposed a hierarchy of needs where the need for esteem,
which reflects respect of oneself and respect from others is highly ranked for one to
believe they are valuable in society. When this need is challenged or un-met then
the resultant outcome will lead to feelings of worthlessness, and helplessness
(Simons, Irwin, & Drinnien, 1987). These expressions were certainly evident in
many of the participant‘s narratives. This insight should inform health organisations
to assess how well they respond to their patients when a complaint is made. How do
they demonstrate their acknowledgement of patients concerns, and can they confirm
satisfaction from the patient that their needs were met?
Chapter 6: Conclusion, Limitations, and Recommendations
170
6.2.4.1. Issue 2: To be Believed and Acknowledged
Wheatley (1998, para 9) puts the concept of the importance of why being
acknowledged and believed is so important, she states ―…whenever a person feels
acknowledged, they want to be in a relationship with us‖. The concept of customer
relationship management (CRM) focuses on identifying and understanding what
consumer‘s desire, and then actively integrating their needs within the
organisation‘s systems. The view is that an effective CRM focus has the opportunity
to establish an improved patient and caregiver experience (Reddy, 2002). This
study has identified that many opportunities have been lost to reflect a positive
patient and caregiver experience as a consequence of ineffective CRM. The
following extracts indicate examples of why the relationship process did not
develop and some of the messages that the participants wanted to convey but did not
get the opportunity to do so.
(Zoey)...I wanted someone to believe me I was in labour,
they acted as if they are the only ones that know what is
going on, they just didn‘t listen…
(Jonathon)... I was looking for an explanation as to why
the situation was allowed to occur, that's what I want, an
explanation...
(Grace)...I don't want money or anything; I don‘t want
anything like that. I just want this to be documented. I just
want this to be actually there somewhere in the records so
he said, ‗so that‘s all you want‘, and I said ‗I don‘t want a
formal apology, I want to speak to the surgeon and, and let
him know because you are copping my flack, and the
Chapter 6: Conclusion, Limitations, and Recommendations
171
people in the office that have had to read my letter are
copping my flack, but the surgeon who is actually the
person you are dealing with all of this stuff because of his
behaviour actually doesn‘t come anywhere near it‘. I said so
that‘s my problem with all of this, that he is actually not
being responsible for what his actions have brought upon
somebody else. I said there are a dozen other people dealing
with my case that have got nothing to do with it and I said
but he is not actually seeing my pain for what his actions
have caused and I said that I don‘t think that, that means
that he doesn‘t actually understand the consequences of his
actions, he doesn‘t really. So I said if I was his daughter or
his cousin or his wife‘s sister, then this would be a different
story so I want to know that I can have a consultation with
him.
The above extracts give insight into the need to have a collaborative
relationship between all stakeholders with the view to improving patient
experiences and satisfaction with the care they have received. A key factor in
ensuring and facilitating the development of a relationship has close associations
with the way information is shared. Findings from this study suggest this is
another area that needs to be addressed.
6.2.5. Theme: How to Make a Complaint is not Clear
Key issues reported by the participants of this study related to
information, how they received that information, how people interacted with
them in terms of passing on that information and difficulties in accessing
information.
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172
6.2.5.1. Issue 3: To be Informed
(Michael)... You know all of this would have taken, was
someone to be in a control box, like a toll booth, sit in there,
people can come up, pull up a chair and say hello I am XX,
I think I have a problem, and someone to say what is your
problem, what will happen, they can tell you exactly what
to expect, you need the information and options and where
to go...
(Emma)...What you need is some sort of concrete link
between the patient and the process and there isn‘t that link
now, the process exists in its own little world and the
patient exists in their own little world and the two worlds
don‘t touch...
(Andrea)...I think that the minute that I came down from
recovery I should have had someone there to debrief me in
there, you know I was full on just laying there on the table
and I was crying that I don‘t want it and everybody just
ignored it, like it was too hard where I should have had
access, whether it be you know some sort of counsellor or
counselling to work through things or yeah, you know
everything starts with knowledge you know...
(Emma)... It seems to be it takes a while for you to get
information back, whether it is because of the volume of
complaints. I believe that probably is what makes the
difference there is just not enough people....
The importance of having clear, concise information and to be informed
about what is going to happen is a fundamental component of effective
communication (Stein-Parbury, 2009) and informed consent (Kavaler & Spiegel,
Chapter 6: Conclusion, Limitations, and Recommendations
173
2003).Without having this capacity for shared, open dialogue, barriers will
continue to occur as demonstrated by the participants of this study.
6.2.6. Themes: Treatment Issues and Perceptions of Negligence
The superordinate themes of treatment issues and perceptions of
negligence have distinct similarities that can be aligned with concepts in the
framework known as Open Disclosure (OD). The framework of OD was
proposed as a National standard in Australia from mid 2008 (Allan, Munro,
2008). OD essentially represents ―open and honest communication with patients
and their families after an adverse incident‖ (Allan, Munro, 2008, 20). As the
findings of this study represent data collected pre 2008 it could be suggested that
similar issues such as those identified by the participants of this study have
influenced the development of open disclosure policies. However, the inception
of OD is more often linked to mitigating the risks associated with patients suing
their health care providers than as a response to improving satisfaction for
patients (Allan, Munro, 2008).
Whilst the underlying principle of OD focuses on adverse events, it
would not be unreasonable to conclude that the use of this type of interaction as
a premise to support effective complaint handling should be realised. With the
view that, ―open and honest communication‖... (Allan, Munro, 2008, 20)
underpins all interactions with patients then, the likelihood of the following
issues presented by the participants of this study should no longer be a major
issue.
Chapter 6: Conclusion, Limitations, and Recommendations
174
6.2.6.1. Issue 4: Taking Ownership if a Mistake Has Been Made
The participants were all united in their expectation of wanting people to
be accountable for any errors or issues that initiated their complaint. Whilst the
OD framework certainly has the right focus, this approach only fundamentally
addresses those incidents that involve actual unintended harm to the patient
(Open Disclosure Standard: A National Standard for open communication in
public and private hospitals, following an adverse event in health care (ODS),
2003). Clearly, participants in this study were saying that they want to have an
opportunity to talk to the people involved in their complaint. Participants
articulated this was not for the purpose of wanting to be confrontational, but
where the aim would be to prevent the same issue occurring in the future. The
following extract from Charlotte captured the essence of this issue.
(Charlotte)... I didn‘t want to pursue anyone or anything
and I made that obvious, what I wanted to be made clear
was that I want them to look into their practices. I want
them to make changes, you know because I have met people
in the community that have had terrible experiences and you
know simple things that could have made it better, but no-
one really wanted to. I guess they were so paranoid that I
am going to try and pursue them or something. That‘s why
everyone kept fobbing all of those things off and yeah,
nobody would just step up and say yeah okay it‘s my fault...
A significant premise of the OD framework is the underlying philosophy
―…that organisations shall be able to demonstrate that they learn from and
Chapter 6: Conclusion, Limitations, and Recommendations
175
improve their performance through continuous monitoring, and by reviewing the
systems and processes in place for meeting their objectives and delivering
appropriate outcomes‖(ODS, 2003, 9). Essentially the goal of OD is a mitigation
strategy against future errors or mistakes.
6.2.6.2. Issue 5: Mistakes Not to Occur Again
Only one of the participants (William) expressed a desire for legal
intervention against the staff involved in the issue that he presented. The remainder
of the participants clearly wanted to ensure that their message was received, so that
the likelihood of the same problem occurring again could be minimised or
eradicated. Examples where participants expressed a desire for the same mistakes
not to occur again have been identified in the following narratives.
(Mia)... It seems obvious to me that to have continuity
would be beneficial for staff to work with the same patients
for the length of their stay...
(Samuel)...I do believe part of it is shortage of nursing staff
you know you can‘t cover all the bases when you don‘t
have enough staff...
(Andrea)... what I wanted is that someone might do
something about it and look into their practices, that was the
main thing that I wrote in my letter, was that they should
look into their practices and that I wanted to know what
evidence did they have, you know like clinical evidence
they had to say that it was necessary for me to have a
caesarean...
(Charlotte)... As a community we should have a decent
hospital, I‘m not sure what will end up happening up there
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176
but I do know that the Doctor is leaving and some nursing
staff are changing. You know it‘s not just there, it‘s
widespread...
(Madeline)... I just want things to be better not just for me
but for anyone who gets sick...
Clearly the intent of these narrative extracts is one of wanting to help to
improve health service delivery. However, another interesting fact that surfaced
from the narratives was that participants felt they were entitled to an apology for
what they went through. This identification once again can be clearly linked to
the OD framework. A key component in the response actions of that process of
OD is to offer an apology to the person/s involved in the adverse event (ODS,
2003). This action does not appear to have influenced effective complaint
handling as yet.
6.2.6.3. Issue 6: To Receive an Apology
It seems only appropriate to conclude the opportunities identified that will
inform service improvement with a comment from Nick. Nick was the first
participant of the study, and his narrative was rich in descriptors about how the
experience made him feel. The feeling of being treated with disrespect and a strong
desire to receive an apology for what he had endured was clearly evident.
(Nick)...I think what I really wanted was an apology and
some recognition of the fact that the people they are dealing
with are people and not slabs of meat, and some change or
some recognition of awareness on their part that this was
not the right way to treat people. I wasn‘t looking for
financial recompense, I just wanted them to acknowledge
Chapter 6: Conclusion, Limitations, and Recommendations
177
that people are people; people in their care are actual real
human bodies and are not just pieces of meat that you can
just shove around to your heart‘s content...
This outcome of being treated with disrespect and the need for an
apology once again can be linked to the desire of wanting to be acknowledged
and believed, with the final view that you do matter as a human being, and that
this a fundamental desire of most people (Simons, Irwin, & Drinnien, 1987).
The preceding section has focused on identifying and presenting the key
issues that the participants shared about their experience of complaining.
Additional issues arising from the thematic process are identified below.
6.2.7. Checking
As part of the PDCA cycle, the third step relates to implementing and using
other mechanisms to validate findings and assumptions that have been made as a
consequence of the initial process under review (Gilmour & Hunt, 1998). In this
study, along with the narratives of the participants, a contextual framework was
used to support the thematic analysis of the interview data, this was drawn from
Lazarus‘ Cognitive Emotive Model of Coping. The emotions data that was
identified revealed a myriad of emotions, but most importantly the recognition that
feelings of anger and anxiety are key predicators of dissatisfaction. The
identification of these emotions adds and supports existing research studies as
presented in section 5.1.6.
The main variable between the studies presented in 5.1.6 and this study is
that the emotion of anxiety and not anger was the dominant emotion identified. This
Chapter 6: Conclusion, Limitations, and Recommendations
178
finding is valuable as it suggests that patients react differently to consumers from
other service areas. This insight has the potential to inform and assist the
relationship that develops between the patient and their service provider. By
understanding that patients don‘t instinctively express anger when they are
dissatisfied, should alert the service provider that vigilance must be directed towards
identifying other predicators of dissatisfaction, such as expressions of anxiety.
6.3. LIMITATIONS
The inability to undertake the first proposed recruitment strategy potentially
limited the views captured in this study. Instead of having a broad Queensland
representation, the study was limited to a 302 km radius of Brisbane CBD. Despite
this, the participants who were involved provided representation across all hospital
peer groupings (as detailed in Appendix I) that the original sampling process had
proposed.
Another limitation that needs to be acknowledged is that the participants
were only representative of English speaking participants from Australia, England,
and New Zealand. The study involved no representatives from culturally and
linguistically diverse (CALD) groups and no participants with Australian South Sea
Islander, Aboriginal, or Torres Strait Islander ancestry. As issues related to
communication were one of the principle reasons the participants of this study
complained, it would be valuable to understand the experience from patients from a
CALD and Indigenous perspective. However, a study on Indigenous use of the
health care system and their concerns should be a study in its own right.
Chapter 6: Conclusion, Limitations, and Recommendations
179
Primarily any interpretative research has the potential to be limited or
influenced by the researcher undertaking the interpretation (Dixon-Woods, Shaw,
Agarwal & Smith, 2004). In relation to this, another limitation that needs to be
considered is the potential impact that deviating from a traditional approach to the
hermeneutic circle as part of the interpretative approach to this study might have on
the findings. Part of the strategy to ensure the validity and rigour of the findings, and
that the process undertaken was transparent, was to ensure a detailed approach was
taken in presenting the findings in Chapter 4. This transparency of process has also
been extended to include extracts of the participants‘ narratives and the thematic
coding process presented in Appendix G. Cohen & Crabtree (2008) believe that the
incorporation of this response within the research process creates the potential to
establish dependability in the interpretive process undertaken.
As with all research studies the issue of the relevancy of the findings must
be considered. As the data that was used to drive the identification of the issues
represents the experiences of patient‘s pre 2007, there is always a risk that these
issues may not be as relevant today as they were when the study commenced. An
additional strategy was put in place to monitor the issue of complaints being voiced
about the Australian health care system, as well as internationally. Table 18 presents
the concluding results as introduced in (Section 2.1) from the Google news alerts
that were used to monitor the relevancy of the studies intent. These news alerts were
automatically sent to the email address of the researcher of this study.
Chapter 6: Conclusion, Limitations, and Recommendations
180
Table 18: Google News Alerts
Google News Alert
Key Alert Terms Date Alert in Place Alerts
Received
Complaints, Health, Australia 18/2/2009 - 11/2010 401
Complaints, Hospitals 22/2/2009-10/11/2010 3,540
Health Quality and Complaints Commission AND
Queensland 23/12/2008-1/11/2010 464
The table displays the number of alerts received in response to the alert key
search terms. Throughout this two-year time period very few days passed without
an alert being raised about some issue resulting from a hospital complaint in
Australia and Internationally. The issue of complaints handling associated with
health care consumers is still as current today as when this initial study was first
proposed.
The discussion covered in the preceeding paragraphs coupled with the
verification processes used to validate their importance, and the limitations
identified, have provided the platform for the recommendations of this study.
The final step in the PDCA cycle is where the opportuntiy to ―Act‖and
decide what changes are needed for improvements to occur (Gilmour & Hunt,
1998). These actions can be realised by presenting purposeful and directed
recommendations with a view to improving the issues identified.
6.4 RECOMMENDATIONS –THROUGH THE LENS OF CHANGE
6.4.1 Acting
The following recommendations have emerged primarily from information
gained from the participants of this study. The voices of the participants have been
Chapter 6: Conclusion, Limitations, and Recommendations
181
heard in terms of developing and presenting the recommendations as a result of this
study. All of the participants were asked, if you were able to improve the complaints
handling process what would you recommend? Overall the participants articulated
the need for health care system reform. Their recommendations were clustered
around the 6 themes presented earlier in this chapter. The identification of these key
themes has the potential to inform health care services of the issues that matter most
to patients. Whilst the study participants articulated the need for health reform at the
time of the data collection process in 2007, today we find ourselves on the precipice
of change that may actually go a long way to realising these opportunities for
improvement raised by the study participants.
The following recommendations will be aligned with an extended version of
the PDCA cycle. The FOCUS—PDCA model has been adapted and utilised in
health care services for the purpose of identifying and solving problems and
processes. The addition of the FOCUS acronym stands for Find, Organise, Clarify,
Understand and Select. The inclusion of this preliminary step to the PDCA cycle is
to focus on discrete opportunities for improvement (Chow-Chua & Goh, 2000). The
recommendations reflect distinct opportunities for improvement that have been
identified as a result of this study. Now that individual issues have been identified
each issue will need to be underpinned by the PDCA cycle to truly represent a
commitment to continuous improvement.
Chapter 6: Conclusion, Limitations, and Recommendations
182
6.4.1.1 Recommendation 1
6.4.1.1.1 Improving Communication
It is recommended and supported by the Health Consumers Queensland
that the framework of the Australian Charter of Healthcare Rights developed by
the ASQHC be embedded and integrated into the education and training
curricula of all health professionals working in clinical settings in Australia
(Health Consumers Queensland, response to the Australian Commission on
Safety and Quality in Health Care‘s discussion paper: Patient‐centred care:
Improving quality and safety by focusing care on patients and consumers, 2010).
For the above to be realised a focused approach is needed to address
ineffective communication and to do so health services need to establish what
their current communication culture reflects. Once organisations establish what
their communication culture reflects, any identified opportunities can be
addressed by providing targeted education and training for their staff. The
Australian Charter of Healthcare Rights developed by the ACSQHC, stipulates
that all Australians have the right to:
…Receive open, timely and appropriate communication about their
health care in a way they can understand… (p. 2)
An interesting strategy to achieve this has been trialed successfully since
2001 in The United States of America. A blueprint for action to underpin A
Patient’s Bill of Rights and later known as Patient Care Partnership in 2003 was
implemented to improve communication with patients and families. The
Chapter 6: Conclusion, Limitations, and Recommendations
183
blueprint details a checklist that can be used to assess strengths and weaknesses
of the hospitals communication culture. The outcome from the checklist has the
advantage of identifying opportunities for improvement. Another important
element of the blueprint strategy is actively seeking ―real-world examples
highlighting various initiatives some hospitals have undertaken to foster better
communication among patients, families and caregivers‖ (Advancing health in
America (AHA), n.d, 2).The use of case studies presents an interesting way to
inform improvement. Perhaps this approach may provide some new insights into
how to develop a culture of effective communication for all stakeholders of
health services.
As part of this recommendation, a closer examination of the results from
the Australian Bureau of Statistics Health Services: Patient Experiences in
Australia 2010 and the pending survey due in July 2011 will inform further
research. The results should provide valuable insights into current barriers
surrounding communication issues in the Australian healthcare system. Another
significant survey that will need to be considered within this recommendation
are the results from the 2010, International Survey of the General Public’s views
of their Health Care Systems Performance. This survey has currently surveyed
11 Countries including Australia, with a sample size of 3,500 participants
throughout Australia (ACSQHC, Windows into Safety and Quality in Health
Care 2010). The opportunity to analyse the results from this survey may elicit
many opportunities that can be further explored in the context of the findings of
Chapter 6: Conclusion, Limitations, and Recommendations
184
this study. For example, a key component of this survey has in the past identified
missed opportunities that are related to ineffective communication interactions.
In 2004, Schoen, Osborn, Huynh, Doty, Davis, Zapert and Peugh reported on the
findings from the 2004 survey. They stated that ―a key goal of efforts to improve
performance and primary care is to make care more patient-centred. On this
dimension, the study reveals missed opportunities to identify patients‘
preferences or concerns, to communicate well, or to engage patients in care
decisions‖( p. 495).
6.4.1.1.2 Relationship Building
It is recommended that best practice leadership innovations that focus on
relationship building with patients and staff to achieve patient-centred care, be
identified and then utilised. The purpose of this recommendation is to ensure that
the Australian Charter of Healthcare Rights developed by the ACSQHC, be
achieved so that all Australians have the right to:
…receive safe and high quality health services, provided with
professional care, skill and competence… (p. 2)
…receive care that shows respect to them and their culture, beliefs,
values and personal characteristics… (p.2)
…join in making decisions and choices about their care about health
service planning… (p.2)
The participants of this study clearly expressed the need and desire for a
stronger connection between themselves and the hospital staff. An immediate
recommendation that can be proposed is to encourage Managers in charge of
Chapter 6: Conclusion, Limitations, and Recommendations
185
specific hospital units to understand the importance of engaging with their
patients on a day to day basis. Patients want to know who is in charge, who they
can talk to if needed. They want to know that the Manager cares how they are
progressing. So, on a very practical note staff look to their Managers for
modelling behaviours. If they hear and see the Manager being interested in the
satisfaction or dissatisfaction of individual patients, then that should have a
positive influence on how they will interact with patients in the future. With the
current health reforms being implemented, a variety of opportunities are
becoming available to assist staff with improving their skills. Research needs to
be conducted on the effectiveness of leadership programmes and the direct
impact that Managers can have in influencing cultural changes within hospitals
to achieve best outcomes. To add further context to this recommendation an
exploration of different health-settings should be considered so as to identify
examples of best practice leadership innovations that are linked with patient-
centred care. With the identification of the aforementioned information and
resources, the opportunity for further research to be conducted in the area of
patient-centred care, hospital communication culture and leadership innovations
will be presented in section 6.5: Future Research, Proposed Study 2.
6.4.1.2 Recommendation 2
6.4.1.2.1 Learning From Our Mistakes—Patient Safety
It is recommended that the Open Disclosure (OD) model be evaluated to
see how the strategies that inform this framework can be used to respond to
Chapter 6: Conclusion, Limitations, and Recommendations
186
complaints that do not result in actual harm. A pilot study could be undertaken in
Queensland and the results disseminated nationally. For example, Queensland
Health, Patient Safety Centre has developed a series of brochures and posters
that reflect the ethos of OD. With significant resources already in place an
opportunity to collaborate with the Patient Safety Centre should be pursued with
a view to capturing what health care consumers want from a complaints
handling process. The Australian Charter of Healthcare Rights also states that all
Australians have the right to:
…comment on or complain about their care and have their concerns dealt
with properly and promptly… (p. 2)
The OD framework currently in place and being utilised by most public
and private hospitals in Australia has been identified as having many significant
opportunities for handling complaints that do not cause actual harm. Key issues,
such as wanting people to acknowledge that a mistake or an issue has occurred,
and that an expectation that someone should apologies for the resultant issue, are
already acknowledged as the required responses to make when an adverse event
occurs. The recommendation would be for the OD framework to be evaluated by
identified interested parties to see how the strategies that inform this framework
can be used to respond to complaints that do not result in actual harm.
Chapter 6: Conclusion, Limitations, and Recommendations
187
6.4.1.3 Recommendation 3
6.4.1.3.1 Confirming Information, Who is Doing What?
It is recommended that detailing a clear representation of what today‘s
complaint resources represent, would be advantageous from a policy planning
perspective. An exercise conducted at the beginning of this study was the
development of a concept map to identify what complaints resources were in
place that health care consumers in Queensland could access (see Figure 2).
Significant changes have occurred since that concept map was undertaken. This
recommendation would be best suited to be undertaken by an Organisation that
already has a mandate for ―championing healthcare improvement‖ namely, the
Health Quality and Complaints Commission (HQCC) of Queensland. The
HQCC welcomes involvement from interested stakeholders via a variety of
mechanisms. The suggestion to undertake this project will be forwarded to the
(HQCC) by the researcher of this study, along with a synopsis of the study
findings after the thesis has been approved.
Another recommendation that the HQCC may be interested in being
advised of (resulting from another issue identified from undertaking the concept
map (Figure 2)), was the identification of a lack of evidence to confirm the
outcomes of significant recommendations that have been proposed over the last
two decades. A retrospective analysis of significant health care
recommendations reflecting complaints handling recommendations should be
valuable to inform policy development into future complaints management.
Chapter 6: Conclusion, Limitations, and Recommendations
188
6.5 FUTURE RESEARCH
The following research studies are proposed from the results of this study:
1. A broader sample with greater diversity of participants would be valuable
to test and compare the findings identified from this study
2. A second study to identify best practice leadership innovations and how
they relate to achieving patient-centred care is proposed. This study can be extended
to include an exploration of the hospitals‘ communication culture and the
interrelationship between leadership programmes and the direct impact that
Managers can have on influencing cultural changes within hospitals.
6.5.1 Proposed Study 1—Broader Sample
The findings of this study have highlighted and extended important
information about complaints handling from a Queensland patients perspective.
However, as the limitations identified, the sample size was limited in terms of
location and the fact that there was no CALD or Indigenous representation. A
broader sample and greater diversity of participants that extends throughout
Queensland would be valuable to test and compare the findings identified from this
study. This proposed study aligns well with the ACSQHC report titled Windows
into Safety and Quality in Health care, 2010, where they acknowledge that:
…An understanding of the actual experiences of patients is essential for an
accurate appreciation of the overall safety and quality of care. Patients have a
unique perspective regarding the health care that they receive, and can provide
information and insights that healthcare workers might not otherwise have
known… (p. 3).
Chapter 6: Conclusion, Limitations, and Recommendations
189
A key strategy that needs to be factored into the study design for this
proposed study is to understand who the audience is, and whose views are being
sought (The Intelligent Board 2010 Patient Experience, 2010). This focus will
ensure that appropriate methodological approaches are chosen to achieve a
broader sample and greater diversity of participants. Whilst undertaking in-depth
interviews may work well with one group of potential participants, this approach
may not be suitable for other potential participants. The use of focus-groups,
telephone interviews, and questionnaires need to be considered and integrated
within the framework of the study design. Another key point is to identify what
initiatives and resources are currently in place that is already engaging patients
about their hospital experiences.
An interesting and innovative approach to collecting feedback from
patients currently in use in New South Wales is a system called the Patient
Experience Tracker (PET). Patients are able to respond to key questions about
the health service and care that they are receiving in real-time. The value of this
approach has the potential for an ‗instant response‘ from staff (ACSQHC,
Windows into Safety and Quality in Health Care 2010). The opportunity to
explore the outcomes from the PET initiative has the potential to provide a
baseline portrait of current patient experiences which can then be used to analyse
past patient experiences from the broader sample size proposed for this study.
Once the above findings have been identified from a broader Queensland
sample, it would be appropriate to consider implementing this study in other states
Chapter 6: Conclusion, Limitations, and Recommendations
190
in Australia. This approach would provide valuable insight into whether systemic
issues are occurring across Australia. A key factor that would need to be considered
in this approach will be to identify the role and influence that the National Health
and Hospitals Network Agreement have had since its inception from April 2010 and
that of the National Performance Authority (NPA), which will be established under
Commonwealth legislation from 1 July 20113.
The opportunity to extend this study to other health care settings, for
example residential, aged care communities is significant. In line with the issues
associated with our ageing population and the impact of chronic disease, this target
group are the most likely to be current and future consumers of the acute-care health
sector (Dolinsky, 1997). Understanding and exploring their experiences should
provide valuable insight into this target group‘s expectation when they are in
hospital. To contrast this study a focus on positive interactions with health care
services, particularly during the complaint handling process, would add further
insight into how to successfully achieve the recommendations identified in this
study
3 COAG today agreed to work in partnership on National Health Reforms to deliver a better deal for
patients and secure the long-term sustainability of Australia’s health system. National Health
Reform will deliver a health system that will ensure future generations of Australians enjoy world
class, universally accessible health care. To give effect to these commitments, every Australian
government signed a Heads of Agreement on National Health Reform and a revised National
Partnership Agreement on Improving Public Hospital Services and committed to signing a full
National Health Reform Agreement by 1 July 2011 (Council of Australian Governments Meeting,
Canberra 13 February 2011, Communiqué).
.
Chapter 6: Conclusion, Limitations, and Recommendations
191
6.5.2 Proposed Study 2—Leadership, Communication Cultures and
Patient-Centred Care
Despite the findings of this study, more research is needed into the
identification of the organisational impacts which mitigate against the use of
patient's complaints to drive improvements. A way of addressing this would be to
implement a pilot study, using an adapted approach to the checklist developed by
AHA as discussed in section (6.4.1.1) that can be used to assess the strengths and
weaknesses of the hospitals communication culture. Depending on the outcome of
the pilot study a larger scale study might be recommended. Essentially the checklist
… focuses on leadership strategies to enhance communication among
hospital staff, patients, families and the community. It’s designed to help you
spark a discussion with your management team, take a look at your policies
and activities and develop strategies for improvement… (AHA, n.d, 3).
An opportunity to enlist all Hospitals in Queensland as a larger scale study
to undertake this survey would be a valuable sample. By identifying how each
Organisation assesses their own culture, the opportunity to identify areas of
excellence as well as areas of opportunity for improvement could be easily
ascertained. The value from this type of study has the opportunity to encourage
collaboration and greater cooperation between hospitals to achieve excellence in
patient-centred care.
6.6 CONCLUDING SUMMARY
The purpose of this study was to understand the lived experience of
individuals who had complained about some aspect of their inpatient stay in an
Chapter 6: Conclusion, Limitations, and Recommendations
192
acute care hospital in Queensland. This exploration has identified many relevant
issues in terms of patient expectations and the gaps in the current health care system.
All the opportunities to identify a more proactive approach in encouraging
our patients to complain when they are dissatisfied creates the potential to inform
and influence improvements in all aspects of the patients experience while they are
in hospital. Without this commitment by individual health care services,
opportunities to improve service will continue to be lost.
While opportunities exist that should enable organisations to improve their
services, there still exists a need to engage all stakeholders to facilitate this. Porter-
O‘Grady (n.d, 290) supports this assumption and states, ―sustainable outcomes can
never be obtained by individuals alone. It is the aggregation of the efforts of all upon
whom the outcome depends that creates sustainability‖. This confirms and
reinforces what was stated in the opening paragraph of this thesis, that the clear
message is that complaint handling should not be managed by a specific department
or an individual but that the responsibility must be assumed and embraced by the
organisation as a whole.
To conclude this study it seems only fitting to remind ourselves that the
concepts of quality health care are not a new phenomenon, this can be illustrated by
the following quotes. Florence Nightingale stated in 1859 that, ―It may be a strange
principle to enunciate, as the first requirement in a hospital, that is should do the sick
no harm‖ (Millington, Carnwath and McGuinness, 1998) and Gibberd (2005, p.
Chapter 6: Conclusion, Limitations, and Recommendations
193
186) quotes a well known surgeon from Boston, Massachusetts, named Ernest
Codman who very wisely voiced this opinion in 1913:
―We must formulate some method of hospital report showing as
nearly as possible what are the results of the treatment obtained at different
institutions. This report must be made out and published by each hospital in a
uniform manner, so that comparison will be possible. With such a report as a
starting point, those interested can begin to ask questions as to management
and efficiency‖
It would be a wonderful accomplishment for the current health care system
reforms if after 150 years following Florence Nightingale‘s poignant words that
patient-centred care can be realised.
Reference List
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Appendices
220
Appendices
Appendix A: Recruitment Flow Chart
Recruitment of Participants
&
Consent process
Initial Contact with
support group
Refer to
attachment 1
Email/letter sent
to identified
support group to
establish contact
with group
NoYES
Identified support
group does not
agree to pass the
information onto
their support
group members.
Identified support
group agrees to
pass on the
request/invitation to
participate in the
study to their group
members in
identified
geographical
locations
Refer to
attachment 2 for
information package
Refer to
attachment 3
for which support
group in which
geographical
location should be
contacted next
Agreement by support
group to pass study
information onto their
members in identified
geographical locations
Make contact
with potential
participants
Consent obtained
from participants
YES NO
Interview details
confirmed with
participants
Interview
undertaken
Interview
Data
transcribed
Thematic
Analysis
undertaken
Copy of transcribed
interview verified as
correct by participant
YES
NO
Commence
process again
Results disseminated to
participating support groups via a
newsletter and Webpage
Changes made and
verified as correct by
participant
THESIS COMPLETED
THE HEALTH - CARE CONSUMER & THE EXPERIENCE OF COMPLAINING STUDY
Plan B: New
recruitment
strategy required.
Rec
ruit
men
t st
rate
gy
un
succ
ess
ful
nsu
cces
sfu
l u
nsu
cces
sfu
l
Appendices
221
Appendix B: Human Ethics Approval Certificate
Appendices
222
Appendices
223
Appendix C: Recruitment Advertisement
Appendices
224
Appendix D: Introduction Letter/Email
Hello
My name is Matylda Howard. I am a registered general and psychiatric
nurse with 25 years of health care experience. I am currently undertaking a
Professional Doctorate in Health Science at the School of Public Health at
Queensland University of Technology.
I am very interested in trying to improve the way health care professionals
and organisations manage and respond to complaints made by our consumers.
I am hoping to conduct face-to face interviews with health-care consumers
who have made a complaint, either written or verbal as a result of experiencing
some dissatisfaction with the care they received whilst they were a patient in
hospital. I believe that before complaints can be used as a strategy to effectively
inform health service improvement, an understanding of the true efficacy of the
complaints handling process, from the health-care consumer‘s perspective, must
be gained.
Participants in this study will have the opportunity to have their
experiences examined for clues as to how to help people who have wanted to
complain but did not, or could not, go through with it.
The findings that may be achieved from this study may assist not only the
consumers, but a variety of other health care support groups, develop appropriate
mechanisms to enable health-care consumers to find their voice and speak up
when they are dissatisfied about any aspect of their care.
The target sample group for this study will be drawn from health care
consumers who have been in-patients from any hospital in Queensland and have
made a complaint about some aspect of their care.
I anticipate that the interviews would be conducted in January 2008, I am
currently developing information packages that each participant will be given.
I would appreciate it very much if you would be able to pass my request
about participating in this study to your group members. I am currently in the
process of obtaining ethics clearance from the University to undertake this study
and once I receive this approval I can forward the information package to you.
Please feel free to contact me if you would like to discuss any aspect of
this study.
I would be very grateful if you could respond to this email indicating
whether your group would or would not be interested in being part of this study.
Thank you for your time
Matylda Howard
Appendices
225
Appendix E: Participant Information and Consent Form
Appendices
226
Appendices
227
Appendices
228
Appendix F: Emotions Checklist
Participant CSP01: Nick
# Emotion Core Relational Theme Emotions Identified in Narrative Total
1 Anger A demeaning offence against me
and mine
√√√√√√√√√√√ 11
2 Anxiety Facing uncertain, existential threat √√√√√√√√√√√√√√ 14
3 Fright An immediate, concrete, and
overwhelming physical danger
0
4 Guilt Having transgressed a moral
imperative
0
5 Shame Failing to live up to an ego-ideal 0
6 Sadness Having experienced an irrevocable
loss
√√√√√√ 6
7 Envy Wanting what someone else has 0
8 Jealousy
Resenting a third party for the loss
of, or a threat to, another‘s
affection or favor
0
9 Disgust
Taking in or being too close to an
indigestible object or idea
(metaphorically speaking)
√√ 2
10 Happiness Making reasonable progress
toward the realisation of a goal
√ 1
11 Pride
Enhancement of one‘s ego-identity
by taking credit for a valued object
or achievement, either one‘s own
or that of someone or group with
whom one identifies
0
12 Relief
A distressing goal-incongruent
condition that has changed for the
better or gone away
√√√ 3
13 Hope Fearing the worst but wanting
better
0
14 Love
Desiring or participating in
affection, usually but not
necessarily reciprocated
0
15 Compassion
Being moved by another‘s
suffering and wanting to help
√ 1
Total interview word count: 3,765
Total interview time: 45minutes
Date of interview: 2/12/2007
Date of transcription: 8/12/2007
38
Appendices
229
Appendix G: CSP Extract of Interview with Coding & Thematic
Considerations
Participant CSP01: Examples of Findings to Reveal Coding & Thematic Considerations
N.B **personal reflections made immediately after interview**
**smiling on introduction-very welcoming**
**demeanour altered when started talking about event**
**tone of voice altered throughout interview-pitch became slightly raised
when relating issues particularly about how he was treated**
Dot point 3: 5
Interviewer: Firstly, can you tell me about the reason why you
made a complaint in the first place?
[Participant 1]: Well, the reason I made a complaint in the first
place is because I did not actually like the way that I was treated.
I was treated, I felt like a piece of meat. I was there as a toy so
that they could play with their new piece of software so they could
test their new machine instead of rather than looking at the
patient who actually had a problem that needing sorting out and
that really irritated me and annoyed me.
Interviewer: Can you tell me a little about the actual event?
[Participant 1]: Okay, I went into hospital because I hurt my
shoulder, they referred me to a test house which is part of the
hospital service, where I went for a ultrasound on my shoulder
because I had a lot of pain in the rotator cuff of my shoulder. So I
went over there and then, when I got into the room there was a
nurse and there was obviously the, the stenographer and another
chap in there. From the moment I walked in the door it was
almost like I was an experimental object they talked over me, they
talked around me the only thing they didn’t do was actually talk
to me there was no explanation of what I was there for or they
read my referral and read that I had pain in my shoulder, but
there was no interaction with me as a subject, there was no
mention the fact the third person in the room was actually not a
stenographer or a nurse he was from the company that
manufactured the software for the machine that they were using
and they were actually trialling the new software and he was
there to tell the stenographer what difference where and what
differences he could expect to see in the software that he was
looking at rather than what he was used to, but this wasn’t
mentioned to me at all at anytime I actually inferred this as I went
through this process and the only direct conversation they had
with me was to tell me to take my shirt off and then position
myself to assist them in the operation of the machine, there was a
complete lack of communication and a complete lack of any sort
of attaining any permission or concurrence on my part that they
were actually using me as an experiment or animal if you like
there was no mention of that all it was just taken for granted that
I would just go along with whatever it was that they wanted and
ANGER- a demeaning offense
against me
SADNESS- having experienced an
irrevocable loss
ANXIETY- facing uncertainty
treatment issues
communication issues
being disrespected
ANXIETY- facing uncertainty
ANGER- a demeaning offense
against me
communication issues
being disrespected
ANGER- a demeaning offense
against me
ANGER- a demeaning offense
against me
communication issues
being disrespected
ANGER- a demeaning offense
against me
ANXIETY- facing uncertainty
ANGER- a demeaning offense
against me
ANXIETY- facing uncertainty
SADNESS- having experienced an
irrevocable loss
communication issues
being disrespected
DISGUST- taking in or being too close
(LANGUAGE) deeply hurt and angry more he spoke about
his feelings about this the angrier he began to feel about the situation.
(LANGUAGE) lack of respect evident in
the language here describing the experience as feeling like an experimental
object and then within ten seconds he is
using language describing feelings of being treated like an experimental animal. Very
intense language use
Appendices
230
Participant CSP01: Examples of Findings to Reveal Coding & Thematic Considerations
wouldn’t have any questions about it and it’s just like wait a
second this is I am the person that is paying for this I’m actually
physically paying money to have this done and yet there was no
mention made of the fact that this third person wasn’t there to
assist me at all I was there to assist them.
Dot point 7:8
Interviewer: During anytime throughout the procedure did you
say anything or say anything to any of them or did you just put up
with it?
[Participant 1]: I put up with it because I was in pain and I was
hoping to get a resolution to the fact that my shoulder was
causing me a lot of discomfort and it was until afterwards when
the pain subsided and I started to think about the way that I had
been treated.
Dot point 14:15
Interviewer: In terms of the hospital complaint system can you
recall whether you were given any information?
[Participant 1]: None, none at all, during my admission process
my wife took me to the hospital I went to the Reception desk and
stood there for a few minutes and one of the Secretaries I
presume from behind the counter walked in from obviously
outside and she stank of cigarettes but that is something else I
was suppose to go into a private room and they didn’t have a
private room for me then, so they said we are going to put you in
a shared room until a private room comes available, which is
really quite strange because everything had been pre-arranged
and I am quite surprised they didn’t have a private room but
anyway I finally got upstairs into the shared room and then about
twenty minutes later I was taken into the private room that I
should have gone in first. The admissions process itself was
relatively smooth but to answer your previous question I wasn’t
given any information and nothing about the hospitals complaints
system whatever, as part of the admission process standing down
stairs at the desk I recall the woman saying there was a
possibility that I might be asked to complete a questionnaire after
my stay, but there was no mention of what sort of percentage of
patients coming in actually get these questionnaires I was not
given one when I left and that was only the reference made at
anytime by anybody about anything to any sort of quality
checking or referencing of what was going on in the hospital at
all.....
Dot point 27
Respondent: It was more cathartic than, it didn’t make me any
more angry by the process of actually writing the letter and even
less angry in the process of receiving the reply, that was the
diffusing point. The coping strategy for me was the actual event of
writing the letter, the old saying that says getting it off your chest,
to an indigestible object or
(metaphorically speaking) idea
did not react straight away
ANGER- a demeaning offense
against me
ANXIETY- facing uncertain
communication issues
being disrespected
ANGER- a demeaning offense
against me
ANXIETY- facing uncertain
communication issues
being disrespected
DISGUST- taking in or being too close
to an indigestible object or (metaphorically speaking) idea
ANGER- a demeaning offense
against me
ANXIETY- facing uncertain
communication issues
being disrespected
communication issues
how to make a complaint is not
evident
communication issues
SADNESS- having experienced an
(LANGUAGE)
Having some control back
(LANGUAGE) constant expressions of being disrespected evident
Feeling out of control-not something he was
used to
Appendices
231
Participant CSP01: Examples of Findings to Reveal Coding & Thematic Considerations
there is nothing worse than bottling something up, you need to get
it out and get it out into the open.
Dot point 30:31
Interviewer: Can you tell me a little bit about your personality
and how you think that influenced you during this event?
[Participant 1]: I’m not a person that suffers in silence if
someone does something to upset me I make it, make it known as
soon as I can and in most cases immediately I have a tendency to
speak I possible before I think a bit but I’m a firm believer in if
you don’t tell someone they are doing something wrong they
don’t know they are doing it wrong and they will carry on doing
it because they think what they are doing is right and it isn’t I
think if people take my comments in a constructive way then it
will be okay I think there is nothing worse than getting into a
situation where you get really upset about something where you
have a valid reason for making a complaint and then you don’t
make a complaint for whatever reason then you winge about it
later to somebody else there’s an old saying in marketing that
goes if you are happy with our service tell your friends and if you
are not happy with our service tell us and what that means to me
is that if you are not happy with the way someone has treated you
then you have to tell the person that has treated you badly or not
to our satisfaction there’s no point in telling all of your friends
that you are not happy because they cannot effect all you are
doing is bad mouthing the person that treated you badly in the
first place but if you tell the person first then maybe he can
change his way and the next person that comes along may not get
treated as you did.
Total interview: 35 dot points
Total interview word count: 3,765
Total interview time: 45minutes
Date of interview: 2/12/2007
Original complaint made: August/2007
irrevocable loss
ANXIETY- facing uncertain
RELIEF- a distressing goal-
incongruent condition that has
changed for the better or gone away
communication issues
ANGER- a demeaning offense
against me
ANGER- a demeaning offense
against me
ANXIETY- facing uncertain
communication issues
RELIEF- a distressing goal-
incongruent condition that has
changed for the better or gone away
being disrespected
COMPASSION-being moved b y
another‘s suffering and wanting to
help
ANGER- a demeaning offense
against me
Appendices
232
Appendix H: CSP–Relational Statements and Superordinate Themes
Examples of Relational Statements Sub & Superordinate Themes
They just didn’t listen
Hard to get information about what was
happening to me
Who is in charge, who do you talk to?
I just wanted someone to tell me what was
going on and how were they going to help me
Fired all these questions at me, not prepared to
listen
I had to ask for pain relief, no-one really cared
enough to listen
I told the nurses that I didn’t want it done, the
midwife wasn’t hearing me
I needed someone to talk to
I wasn’t being listened to
I spoke to everyone who would listen
I had to find my voice and stand up and get
people to listen to me
Having to fight to be heard
No-one is listening
Poor communication
I needed someone to talk to
No-one really cared enough to listen
I was left with no explanation
It was hard to get information about what was
happening to me
I didn’t receive any acknowledgement
Communication Breakdowns
Ineffective Communication
(more detail available in
Appendix M)
No-one cares
Poor standard of care
No confidence in graduate nurses, where are
all the staff with experience?
Nurses were too busy
Not the same sort of care that you received by
nurses years ago
I would have been better off in a public hospital
There was no standard procedures carried out
Standard of care provided was not right
Different nurses every day
No consistency in care
I was so fearful and scared and I didn't feel as
anyone cared
I had to ask for pain relief
I wasn’t receiving the attention or care that I
should
Didn’t care that I was in pain
My father is constantly vomiting
Disparities in Care
Standard of Care is Not
Acceptable
(more detail available in
Appendix O)
Appendices
233
Examples of Relational Statements Sub & Superordinate Themes
There is a line in the sand that the hospital
draws that says okay we are not going to spend
any more money on this person
I battled for everything
I wasn’t wrong about the situation because I
was in pain....
I wanted someone to believe me I was in
labour, they acted as if they are the only ones
that know what is going on, they just didn’t
listen
Poor standard of care
No confidence in graduate nurses, where are
all the staff with experience
Treated as a test subject not as an individual
I felt like I was a nuisance
I was so fearful and scared I didn't feel as if
anyone cared
I was left to my own devices
No one cared enough to listen
Very short and very rushed
Treated as a complainer
I can’t believe this happened to me I am not a
bad person...
I found it extremely degrading
Dysfunctional Relationships
Treated with Disrespect
(more detail available in
Appendix N)
No information about complaints system, had
to work it out on my own
No one to tell you what to do
No one to identify as being in charge to tell that
you are unhappy with care
No information on who to speak to
I worked through the system and by trial and
error I got different people to listen to me
I had to work it out, I spoke to everyone who
would listen to me
I was sent from pillar to post
No one offered to listen me
No information
I didn’t get any clear information from my
Doctor
I needed someone to talk to
No information about how to complain, took
me 12 months to get my complaint heard
I didn’t know which way to go to make a
complaint, I relied on my friends
Going public with your complaints is not a
sense of good will
Information Roadblocks
Ineffective Complaints
Handling Systems
(more detail available in
Appendix P)
Appendices
234
Examples of Relational Statements Sub & Superordinate Themes
I actually went looking for the information
because nothing was given to me to fill out
I spoke to a lot of different people and the main
information that came back was for me to get in
contact with your local MP which I did
Where is their duty of care?
I was treated very badly
In the beginning I couldn’t talk about it without
bursting into tears
No one cares
Poor standard of care
I wanted the nurse and doctor charged with
causing the death of my wife.
We were treated badly and I didn’t have the
opportunity to give informed consent
How could they get it so wrong
Is not justifiable for a major operation
So many issues went wrong?
Her death was preventable
I told the nurses that I didn’t want it done
One nurse in particular that I found very
difficult and I blame her for the circumstances
surrounding the death of my wife
You know there is saying that says doctors bury
their dead, no what is it, doctors bury their
mistakes
I am really worried that I am going to take him
out of here in a box
Dereliction of Care
Perceptions of Negligence
(more detail available in
Appendix Q)
Appendices
235
Appendix I: Peer Grouping Criteria
The peer grouping is based on the following criteria.
1. Principal Referral & Specialist Hospital
a. Major city hospitals with >20,000 acute casemix-adjusted separations and
Regional hospitals with >16,000 acute casemix-adjusted separations per
annum
b. Specialised acute women‘s and children‘s hospitals with >10,000 acute
casemix-adjusted separations per annum4
2. Large Hospitals
a. Major city acute hospitals treating more than 10,000 acute casemix-
adjusted seperations per annum
b. Regional acute hospitals treating >8000 acute casemix-adjusted
seperations per annum, and remote hospitals with >5,000 casemic-adjusted
seperations. 5
3. Medium Hospitals/ Small and Rural Hospitals
a. Medium acute hospitals in regional and major city areas treating between
5,000 and 10,000 acute casemix-adjusted seperations per annum.
b. Medium acute hospitals in regional and major city areas treating between
2,000 and 5,000 acute casemix-adjusted seperations per annum, and acute
hospitals treating <2,000 casemix-adjusted seperations per annum but with
>2000 seperations per annum.
c. Small regional acute hospitals (mainly small country hopsitals), acute
hospitals treating <2,000 seperations per annum, and with less than 40%
non-acute and outlier patient days of total patient days.6
4 National Hospital Cost Data Collection (NHCDC) Round 9 (2004-05) Peer Group Package, page 4 5 IBID 6 IBID
Appendices
236
Appendix J: Leximancer Concept Maps
Figure 11: Thematic Concept Map—Isabella and Michael
Figure 12: Thematic Concept Map—Andrea
Appendices
237
Figure 13: Thematic Concept Map—Charlotte
Figure 14: Thematic Concept Map—Audrey
Appendices
238
Appendix K: Group and Participants Findings of Emotions Data
Complaint Study
Participant(CSP)
Anxiety
n=432
(100%)
Anger
n=306
(100%)
Disgust
n=99
(100%)
Sadness
n=83
(100%)
Fright
n=51
(100%)
Shame
n=37
(100%)
Relief
n=23
(100%)
Hope
n=23
(100%)
Guilt
n=16
(100%)
Happiness
n=10
(100%)
Pride
n=10
(100%)
Love
n=4
(100%)
Compassion
n=4
(100%)
Jealousy
n=0
(100%)
Envy
n=0
(100%)
CSP01-
NICK
n=14
(3%)
n=11
(4%)
n=2
(2%)
n=6
(7%)
n=0
(0%)
n=0
(0%)
n=3
(13%)
n=0
(0%)
n=0
(0%)
n=1
(10%)
n=0
(0%)
n=0
(0%)
n=1
(25%)
n=0
(0%)
n=0
(0%)
CSP02&3-ISABELLA
& MICHAEL n=41
(9%)
n=51
(16%)
n=4
(4%)
n=10
(12%)
n=3
(6%)
n=2
(5%)
n=0
(0%)
n=1
(4%)
n=3
(19%)
n=0
(0%)
n=2
(20%)
n=0
(0%)
n=0
(0%)
n=0
(0%)
n=0
(0%)
CSP04-
MIA
n=22
(5%)
n=15
(5%)
n=12
(12%)
n=5
(6%)
n=0
(0%)
n=8
(22%)
n=2
(9%)
n=1
(4%)
n=0
(0%)
n=0
(0%)
n=0
(0%)
n=1
(25%)
n=0
(0%)
n=0
(0%)
n=0
(0%)
CSP05 –
GRACE
n=48
(11%)
n=39
(13%)
n=7
(7%)
n=10
(12%)
n=12
(24%)
n=8
(22%)
n=8
(35%)
n=3
(13%)
n=5
(31%)
n=5
(50%)
n=4
(40%)
n=0
(0%)
n=2
(50%)
n=0
(0%)
n=0
(0%)
CSP06-
WILLIAM
n=18
(4%)
n=14
(5%)
n=5
(5%)
n=4
(5%)
n=2
(4%)
n=1
(3%)
n=0
(0%)
n=3
(13%)
n=2
(13%)
n=0
(0%)
n=2
(20%)
n=2
(50%)
n=1
(25%)
n=0
(0%)
n=0
(0%)
CSP07-
AUDREY
n=22
(5%)
n=15
(5%)
n=12
(12%)
n=5
(6%)
n=0
(0%)
n=8
(22%)
n=2
(9%)
n=1
(4%)
n=0
(0%)
n=0
(0%)
n=0
(0%)
n=1
(25%)
n=0
(0%)
n=0
(0%)
n=0
(0%)
CSP08-
MADELINE
n=15
(3%)
n=9
(3%)
n=3
(3%)
n=2
(2%)
n=4
(8%)
n=2
(5%)
n=1
(4%)
n=1
(4%)
n=1
(6%)
n=0
(0%)
n=0
(0%)
n=0
(0%)
n=0
(0%)
n=0
(0%)
n=0
(0%)
CSP09-
ANDREA
n=39
(9%)
n=23
(7%)
n=8
(8%)
n=7
(8%)
n=7
(14%)
n=0
(0%)
n=0
(0%)
n=0
(0%)
n=0
(0%)
n=0
(0%)
n=0
(0%)
n=0
(0%)
n=0
(0%)
n=0
(0%)
n=0
(0%)
CSP10-
CHARLOTTE
n=42
(10%)
n=19
(6%)
n=13
(13%)
n=5
(6%)
n=2
(4%)
n=5
(22%)
n=0
(0%)
n=5
(22%)
n=0
(0%)
n=1
(10%)
n=0
(0%)
n=0
(0%)
n=0
(0%)
n=0
(0%)
n=0
(0%)
CSP11-
KATHERINE
n=27
(6%)
n=16
(5%)
n=9
(10%)
n=5
(6%)
n=0
(0%)
n=0
(0%)
n=2
(9%)
n=1
(4%)
n=0
(0%)
n=1
(10%)
n=0
(0%)
n=0
(0%)
n=0
(0%)
n=0
(0%)
n=0
(0%)
CSP12-
EMMA
n=34
(8%)
n=19
(6%)
n=6
(6%)
n=5
(6%)
n=4
(8%)
n=0
(0%)
n=0
(0%)
n=2
(9%)
n=0
(0%)
n=0
(0%)
n=0
(0%)
n=0
(0%)
n=0
(0%)
n=0
(0%)
n=0
(0%)
CSP13-
JONATHON
n=21
(5%)
n=14
(5%)
n=2
(2%)
n=2
(2%)
n=5
(9%)
n=0
(0%)
n=2
(9%)
n=0
(0%)
n=0
(0%)
n=0
(0%)
n=0
(0%)
n=0
(0%)
n=0
(0%)
n=0
(0%)
n=0
(0%)
CSP14-
SAMUEL
n=29
(7%)
n=17
(6%)
n=6
(6%)
n=4
(5%)
n=0
(0%)
n=0
(0%)
n=1
(4%)
n=0
(0%)
n=0
(0%)
n=0
(0%)
n=2
(20%)
n=0
(0%)
n=0
(0%)
n=0
(0%)
n=0
(0%)
CSP15-
AVA
n=15
(3%)
n=9
(3%)
n=5
(5%)
n=4
(5%)
n=0
(0%)
n=0
(0%)
n=2
(9%)
n=2
(9%)
n=0
(0%)
n=2
(20%)
n=0
(0%)
n=0
(0%)
n=0
(0%)
n=0
(0%)
n=0
(0%)
CSP16-
ZOEY
n=45
(10%)
n=35
(11%)
n=5
(5%)
n=9
(11%)
n=12
(24%)
n=3
(8%)
n=0
(0%)
n=3
(13%)
n=5
(31%)
n=0
(0%)
n=0
(0%)
n=0
(0%)
n=0
(0%)
n=0
(0%)
n=0
(0%)
Combined % 39% 28% 9% 8% 5% 3% 2% 2% 2% 1% 1% 0% 0% 0% 0% 100%
Table 19: Complaint Study Participants (CSP) Group Findings—n and % Emotions Identified in Narrative
Appendices
239
Appendix L: All CSP—Combined Percentage of Emotions—Pie Chart
Figure 15: All CSP—Combined Percentage of Emotions—Pie Chart
Appendices
240
Appendix M: Theme 1: Ineffective Communication (extract examples)
...The only direct conversation they had with me was to tell me to take my
shirt off and then position myself to assist them...
..Nurse M told me to mind my own business, I found Nurse M to be
surreptitious not telling me what is going on with Isabella’s meds...
...the letter refers to go to this person and this person, they didn’t say
anything about her medication it just says the medical officers are
qualified and all of this type of thing, so that rings alarm bells to me, I
asked a simple question, very simple it might be non-academic and all of
that it’s just like a normal bloke asking a question, can you answer? That
letter and that response is gobbly gook to me, that says to me ―I hung my
washing out last week and I wash a car and it started raining so I had to
bring my washing in and oh dear it was still wet‖, you would be fair to
say to me what has that got to do with the hospital...
...They told me while I was having the interview with child safety in the
hospital, that’s when they took her, I didn’t even get to say goodbye to
her...
...On numerous occasions a nurse would come in and say hi, I’m Marj,
and I will be looking after you, and you would rarely see them again. I
am aware of the huge changes in nursing but there seems to be such
emphasis on the technical side and such a lack of compassionate bed
side manners and understanding on the nursing side. A smile, a few kind
words and an attempt to make the patient comfortable are not too much
to expect. Emotionally the patient needs and requires these things to stay
focused and positive...
...The doctors are dealing with a different person every two seconds,
they’ve got that next person, different case, different client, different
whole person and they have got to cut through all of that, still be
personable and get to what the issue is and that’s a difficult thing to do.
So, I really think there needs to be an issue of them acknowledging their
patients at the beginning type of thing, and what are we here for and also
giving them clear directions. I know that is really difficult to say but
because it takes energy and they often don’t have the energy to do that
because their brain space is consumed with taking care of what blood
you needed for that last patient, they may be going into surgery in an
hour but they still have ten other patients before they go there and you
know how do I not know that may have happened with my surgery. You
know I believe that a lot of complaints out there are just
miscommunication and I think that's what most of it is, I hear a lot of my
friends complain about this that and the other about what has happened
to them and they haven't told the right people...
Appendices
241
...That one statement, is there anything else that I can clear up for you?
Is so engaging, even right at the time when you are so ill you don’t think
about all of those things and later on you go what about this? And what
about that...
. ..She went off without speaking to me...
...I said to a nurse once I said it was a young guy, he was a nice enough
guy and I said to him is my dad going to die? I know eventually we are
all going to die but he was just vomiting all the time and no one was
doing anything it was ridiculous, he said to me we are all going to die
one day and I said which I thought was a stupid answer he knew where I
was coming from...
... If I said that once I said it heaps of times, that nobody is doing
anything about this vomiting...
... I could never get to see the doctor I always seem to miss the doctor
twice the ward sister put a call in for the doctor to come back to see me
he never came back to see me. If I seen a doctor on when I arrived in the
ward they would, they didn’t want to give me any information because
they were not his doctor. They were quite loath to actually you know to
speak to me...
... I know one nurse she really got fed up with me because I would go in
and say to dad what has happened today? Did you see the doctor? well
dad was old and he would say yes the doctor came but he didn’t really
seem to say much, so the next thing I would do was go out to try and
catch the nurse and find out what was going on because you know dad
was vomiting and all of this sort of stuff and in the end I again was
talking to one of my friends and she said look forget about the nurses on
the ward if you can’t get hold of the doctor, talk to the charge nurse, the
unit manager so I spoke to one of the nurses who said the best time to get
her was between seven and seven thirty in the morning she’s not that
busy then and you should be able to talk to her...
... There was a lack of communication, the things that I would have liked
to have to would have been to be able to talk to the doctor I know the
public doctor is stretched for time...
... I kept saying to the midwife I don’t want this, this is not what I want to
happen and so on, the other thing was that my son was taken away
because they said it was routine practice so he was taken away with my
husband and the midwife apparently said to my husband oh I am so
worried about your wife, she is so distraught about having the
Caesarean but no-one actually never said anything to me at all...
Appendices
242
... I was given a spinal but I wasn’t given any information at all I was not
asked, consulted, not given any options we just assumed that in the heat
of the moment that it must have been something really wrong...
... She just couldn’t quite grasp what I was getting at. We worked
through a lot of things, which like helped me with my coping and that
sort of thing but I still felt that at the end of the session she still didn’t get
it...
... I was flat out trying to walk, they just watched me shuffle out, holding
my abdomen, no shoes, in my pyjamas and I didn’t have a bra on and I
was half way through my pregnancy they just stood there and watched
me shuffle out without anyone helping I just felt, I felt like crap I did I
thought a dog would be treated better than this so to me had there been
no communication. I was telling them but I don’t think anyone was
listening. I think because they get a mindset they said it was urinary tract
infection so that’s what it was....
...They never listened...
... I think the communication obviously has been a real break down
between patient and the medical staff. You know if the doctor had just
said right at the beginning I’m not sure what’s wrong but I am concerned
I think you better get yourself up to XX Hospital straight away. I would
have been okay for sure, that’s all I wanted...
... I know I sound like a whinger but that evening when the specialist
came in he had such a terrible manner and my husband was in the room
with me and I think my daughter was there; yes she was there also that
night. He walked in and I know they work long hours and that they are
rushed, but when you have been laying for a day, in pain, not knowing
what is going on, it is very scary he came and turned off the TV and just
ordered my daughter and husband out, he didn’t give them a chance to
say anything, he just started firing all of these questions at me and
criticized the doctor in A&E for what he given me and more or less in a
roundabout way said why are you in hospital? I felt awful I wouldn’t be
here for no reason...
... Because it was late admission time I didn’t get to see a specialist that
night, I was just monitored through the night with the pain and
everything else. That was Monday evening and then I saw the specialist
because he did his rounds at night not until the next night, the Tuesday
night was the first time I saw anybody...
Appendices
243
Appendix N: Theme 2: Treated with Disrespect (extract examples)
...I did not actually like the way that I was treated. I was treated, I felt like a
piece of meat...
...I walked in the door it was almost like I was an experimental object they
talked over me, they talked around me the only thing they didn’t do was
actually talk to me there was no explanation of what I was there for or they
read my referral and read that I had pain in my shoulder, but there was no
interaction with me as a subject..
...I felt like they had no concern for me as a person or the injury that I was
suffering from...
... I found it extremely degrading...
...Nurse M said I should be made a ward of the state and my pension be
taken away from me, because she said I can’t manage my money. I’m good
at maths I do have some trouble with reading...
...Nurse M with her attitude and they reckon that there is nothing wrong with
it, well Nurse M said to two people, Government officials that people who
have a mental illness or a disability should not have children and that’s her
attitude that they should be removed...
...One morning I was shown a dining room style chair and told I had to get
out for half an hour, I replied I didn’t think that I would be able to sit in this
style of chair for that period of time, (I was thinking doesn’t she even realise
I have four tubes hanging out of me?) And the nurse asked ―why‖ in an
unsympathetic and inpatient tone...
..The doctor, he was vey dismissive he looked even disgusted that he had to
look at it down there, that’s fine I understand as a human factor that it is not
going to be pleasant every time and I went I’m really sorry you have to look
at me down there...
… I saw the nurse that was with the doctor in the morning and the one who
was suppose to verify the appointment. I said to her why she didn’t make the
call, you know what she said, she said it’s not my job the doctor should have
made the call. Can you believe that...?
… To this day I still can’t believe what happened and how little help we
received and the lies that were said to cover up their mistakes...
… Going back to the nurses it didn’t seem like they looked for things they
were there to make the beds, take the temperature they were lovely , they
were nice but they didn’t seem to look for things and there was you know
when my friend went around to visit my dad he was sitting there, he had been
undressed and I think he had a gown put around him, but he was shivering
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and she went and covered him up with blanket because they had forgotten
they had undressed him for a shower....
…From a dignity perspective like Dad told me that he wanted to go to the
toilet for a poo now they got him undressed for a shower I think and the
nurse had got called away and by the time she came back and wheeled him
into the toilet he was doing it on the floor , the dignity side of it, he had this
thing that was fitted on the end of his penis and it had come loose and you
know the nurse hadn’t been able to get to him for probably over an hour and
his pyjamas were all wet...
...I had nurses come in and viewed him, he was nine pounds, which is not a
huge baby but fairly normal, and these nurses would say aren’t you lucky
that you had a Caeser? Can you imagine having to do it naturally? Imagine
if you had him? I didn’t have a choice I would tell them....
… I find he is just looking at me as if I am an idiot I don’t have a medical
degree so I must not know anything it is really insulting really to my
intelligence. I am not claiming to be the smartest person in the world but I
am certainly not an idiot...
… I had like a guidance counsellor or a social worker she was horrible,
truly horrible. I remember walking around up in hospital XX and she kinda
would breeze in and breeze out and I remember smiling at her and she
literally rolled her eyes up at me and I thought she must be having a bad
day. Then she came to see me and said something, so I still really don’t know
why she came to visit me and I never saw her again, she said she would
come back but she never did. I thought I have been here a month, in
Brisbane for two weeks and hospital XX for four weeks and I never saw her
again and she didn’t come and see me until towards the end of my stay...
…I think to me things would have been a lot better had he been a bit more of
a hands on doctor that to me would be it in a nutshell I didn’t expect him to
be able to operate on me or do anything like that, he simply came across as
someone who I was wasting his time and that was really upsetting and
especially when I felt like he knew who I was and you know he was familiar
with me. I felt as though I was treated, I don’t know like a real dreg of
society and that was really humiliating as well...
… Radiology receptionist was very rude and she said well you can’t get in
today...
… I was obviously in great pain but they did not seem to be any
consideration for that and when the doctor was pushing me, it just felt like a
blunt drill trying to come through the back of my head, I just felt where is
your compassion, you know?...
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Appendix O: Theme 3: Standards of Care are Not Consistent (extract
examples)
...I put up with it because I was in pain and I was hoping to get a resolution
to the fact that my shoulder was causing me a lot of discomfort and it was
until afterwards when the pain subsided and I started to think about the way
that I had been treated...
...It was after three days they say having baby blues, but no-one seemed to
want to listen to me, I felt my depression kicking in but they would just say its
fine it’s just normal baby blues kicking in...
...Didn’t want to give it to Isabella because of the expense, because we could
not pay for it it’s a hundred dollars a tablet or something and we could not
pay for it so basically they said no, she is a pensioner, piss her off, we want
the money, show me the money then you can get well, don’t show me the
money stay sick...
... I’m going on there is something wrong, please someone give us a hand...
...Maybe the nurse in me knows too much, but I felt that many of things could
have been easily remedied with a little bit of thought...
...I felt that I saw a different nurse every day so that no-one really knew or
cared in my opinion how I was...
...Quite a shock to me to see the deterioration in the nursing standards and
to realise that there is a need for improvement in some areas...
...I was unfortunate to have several young graduates attending me that they
did not give me any confidence that they knew what they were doing. One
graduate nurse was teaching the other how to aspirate my Ryles tube;
another graduate nurse washed me with cold wipes whilst I shivered...
... . Not one nursing staff ever asked me if I eaten my meal, I wonder how
many of the elderly patients had their trays removed without even touching
the food...
...Well I didn’t see the same nurse twice so in my opinion no-one really knew
whether I was getting worse or better. I didn’t see the same nurse ever, so
there was no continuity and I felt that sometimes it was a case of the blind
leading the blind...
...They actually completely did the wrong thing and I couldn’t understand
how that could happen so I was in shock and I couldn’t believe that it
happened...
...I rang the hospital and said I need to speak to someone as I have had the
wrong operation done on me and they said what are you talking about? I
ended up speaking to the Director on the phone, I spoke to the head registrar
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first then the Director and they said would you like to come back in, I said I
don’t actually want to come near you...
... I couldn’t understand how this simple procedure gone awry and I wanted
it to be spoken about and for somebody to know that this is happening
because this was a very respected surgeon, this Doctor X was and is
probably still so and I was concerned how that could happen under his care
and I felt like a guinea pig see and I actually felt like a guinea pig, I thought
what were they actually doing were they experimenting with something, what
were they doing so I thought how could they get it so wrong?...
...There is pressure in every hospital I know that but sometimes when there
isn’t that sort of urgency people can be looked at from a different basis and
at a different level but because of that there does not seem to be that feeling
that someone is going to urgently look at me it’s like we will come to you,
maybe this is just the Queensland way, and that’s okay I do love Queensland
because of that because it does slow things down...
... The reply I got was we can’t do anything about getting him out of bed he
has to be assessed by a rehab person, I think he had been in hospital about
three days then and so for Dad at his age that’s too long to be just sitting
and lying in a bed and we came across issues where Dad was a very very
thin man and there was no curtains on his windows, he had a room of his
own because he had they use to say he got a bug in his lung, but he had, had
it there for years but it always meant that he went into isolation and we
couldn’t provide anything like a hot water bottle or to try to work out ways
to keep him warm he use to get very cold but he couldn’t have too many
blankets on his bed because it affected the arthritis in his feet...
... They were short-staffed and so the nurses would put his food outside on
the tray outside his room and if there wasn’t someone visiting him at the time
to take it in and feed it to him it would sit out there and be cold...
... The issue that started to come up the most was he started vomiting all the
time and then we would have ridiculous situations where like I came in one
day and Dad was, the nurse was trying to give him his tablets to stop him
throwing up and he was you know he was trying to get it in between him
throwing up you know it was just ridiculous and dad was in hospital for six
weeks before he passed away and you know probably four weeks down the
track because I was constantly talking to people I was feeling, I was feeling
often at my wit’s end as to try to I felt it was my responsibility to work out
how I could get my dad well if I was I felt at one stage like I should sign Dad
out and take him home...
...My husband was sent out of the room and I was just like told to lay down,
we just really thought something must be really wrong when you are in a
situation like that I was fully dilated just in transitional contractions I
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couldn’t really sort of sit up and go hey let’s talk about this. We just thought
that something must be really wrong and when my husband was sent out then
I was sort of yeah, then all I wanted to do was get up on the trolley and they
kept saying I had to lie down and I was having a really intense back labour
and the midwife kept putting her hand on my chest and saying no you have to
lie down, you will fall off the trolley...
...The other thing when my son went down to the nursery whatever they do
down there well they were short staff on most days and on this day it was
three hours before I got to see him because I had to call out for someone to
bring him to me so besides the stress of the Caeser then I had to continually
ask for someone to bring me my baby I just didn’t get the bonding that I
needed...
... I don’t really think they care I really think that they are just stuck in their
work practices, very regimented, that’s the way they do it, because that’s the
way they have always done it...
...The doctor did not touch me he didn’t examine me I was, the heartbeat of
the baby wasn’t checked or anything like that because the second day I was
in the huge amounts of pain I was in I would have thought that he would
have been a little bit more attentive than he was and the nurse that I dealt
with also was very uninterested when I went in the second day she said Oh!
Your colour is better than yesterday. It was the first comment she said, that
your colour is better than yesterday. I just thought to myself, Oh come on....
...The whole time I was worrying, in pain and wondering what was
happening to me but they didn’t say a thing about any delays or anything I
just didn’t think that was very good customer service. I had to actually go up
to the counter and ask when I would be going in, and then obviously they
were rushed the radiologist that came and took me through was very short
and very rushed and didn’t seem to care that I was in pain, he just pushed
me back to lay down for the scan...
... Since we were already at the hospital I would go to the Accident and
Emergency rooms so they said it was going to be a couple of hours before I
could be seen as they said it was really busy. It was about seven-thirty before
I got to see anybody, by this time I was in tears with the pain; they did give
me something for the pain, which did help a bit. I saw the doctor in A& E
and he put me on antibiotics because I had bruising above my eye which he
could not explain. So I was on a antibiotic drip and he also gave me some
morphine for the pain and it was about, I don’t know maybe it was after nine
o’clock that night before I was actually taken up to the ward....
...It was the next morning I think there was a change of shifts with the nurses
I mentioned to one of them that I didn’t like the doctor, the specialist and
before I even finished saying that the nurse was nodding, she already
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recognised that he is not very good with patients she was aware of his
manner and she said to me if I wanted to change specialist I would need to
speak to him first not to the nurses. Well I thought well no, his attitude to
what I had already seen of him so far regarding his attitude I knew that
would not go down very well so I decided not to change...
... You at least think that you will get people to do their job at the minimum...
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Appendix P: Theme 4: Information is Not Clear (extract examples)
...Wanted for it to be informative and registered somewhere, to be real so
that it wasn’t just some complaint that was thrown in the bin somewhere, so
that there was some value from it so that if this sort of thing happened more
often than me and if someone else was hurt that they had some type of type of
recourse and I was very pleased with my ability to be able to voice to that
surgeon and to that Director...
...In the first instance it's the person you are complaining about I think it is
better to do the human thing and go hey I expect you to treat me this way and
I understand that you may not have but you need to be told not the nurse at
the counter it doesn't make a difference you really need to find way to speak
directly with the person involved and that's a very difficult thing to do...
...They eventually sent me another letter from the other board and said that
this is what we have concluded from this and if you want to take this further
these are the people to contact. I chose not to take it further because it was a
pointless exercise it wasn’t anything that was a permanent injury, I healed
and the area treated so it was okay I am concerned, my concern was when I
went to try and get that, it was very difficult...
...I wasn’t given any information and nothing about the hospital’s complaints
system whatever...
...I was left to figure out what the system was by myself it eventually did work
in my favour because I did make a complaint by letter and I did receive a
resolution to that complaint but in terms of the complaints handling process
I don’t know what the process is so I don’t know if what I did was actually
following the process because no-one told me what the process was...
...I wasn’t given any opportunity to vent my grievance to anybody; no-one
actually didn’t give me the opportunity to do anything about it...
...I just needed to know what was going to happen, if there was some sort of
person who could tell me this is what is going to happen this is what we are
going to do without Government interference or red tape bullshit and go this
is what is going to happens, and these are your rights. When Participant 3
was in hospital neither of was given any information on what to do, I was in
fact kicked out of the hospital...
...I’m a dunce and I did not know the system or whatever no legal help and I
didn’t know what to give them. I’m going in there like someone who has just
walked out of the pub complaining about John Howard, you know what I
mean...
...They say you must type, you must type we can’t even get anyone to help us
to type a letter for us I had to pay for that there that cost me thirty dollars to
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have that complaint typed about the nurse, because I hand write they said it
would look at lot better if it was typed I paid thirty dollars, I said shit if I
have to do that I’m going to need three thousand dollars in typing how in the
hell can I do it?...
...They give you lines on where to go further, like the letter I got from the
hospital about if you want to take it further you need to contact the liaison
officer, well I’ve already gone through them and they told me to go away and
now this executive from the hospital I asked her have you interviewed the
nurse and how is going with the doctor’s reports and she said don’t worry
about those we are doing the investigation and when we talk to the Nurse it
will be alright, then I got this letter about a week later and it talks about the
nurse, it’s all bullshit, the whole system is rigged, rigged so you can’t
complain or you can complain if you know the avenues, then it’s knocked
back knocked back and that’s the way the government has designed it...
...It’s like if you go and make a complaint about this house for example, it
has asbestos who do you complain to it’s the government if you go in to the
wrong gate you have to go back to zero then you have please follow this
path, that’s what I have been getting ...
. ..Another thing is the expense of trying to do a complaint, the paperwork,
photocopying, paying for typing...
...The complaints system works you until you run out of any further avenues,
they know how much money you need how long they can push you what it
takes, they don’t want you to be knowledgeable about the complaints system,
and I have to find another avenue I just have to...
...I didn’t receive any information of that type and no-one mentioned
anything about how to go about or who to talk to if you were unhappy about
anything going on. I really think that while you are in hospital you should be
given some sort of number to ring if you are unhappy with something, a lot
of people don’t really know how to express themselves or what to say and for
the hospital’s benefit too, if I was a CEO in a hospital I would want to know
if someone was not happy and I think really if they don’t know that their
patients are unhappy how can they know how to correct it...
...Wanted for it to be informative and registered somewhere, to be real so
that it wasn’t just some complaint that was thrown in the bin somewhere, so
that there was some value from it so that if this sort of thing happened more
often than me and if someone else was hurt that they had some type of type of
recourse and I was very pleased with my ability to be able to voice to that
surgeon and to that director...
...In the first instance it's the person you are complaining about I think it is
better to do the human thing and go hey I expect you to treat me this way and
I understand that you may not have but you need to be told not the nurse at
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the counter it doesn't make a difference you really need to find way to speak
directly with the person involved and that's a very difficult thing to do...
...They eventually sent me another letter from the other board and said that
this is what we have concluded from this and if you want to take this further
these are the people to contact. I chose not to take it further because it was a
pointless exercise it wasn’t anything that was a permanent injury, I healed
and the area treated so it was okay I am concerned, my concern was when I
went to try and get that, it was very difficult...
...I actually didn’t know anything about the complaint system of the hospital
I had to work it everything out myself it was only up to me to work it out ,
chasing people and finding out information for myself that I was able to
work out what I should do. There was not anybody there that was prepared
to help me and I just had to work everything out myself...
... I spoke with the Director of Nursing of the hospital; I had a meeting with
her. I also made a complaint to the Health Rights Commission, I wrote a
detailed letter to them explaining everything that had occurred. After going
to the Health Rights Commission the hospital wrote me a letter, but I wasn’t
happy with the letter because it didn’t address any of the issues surrounding
the nurse and her failure to confirm the X-ray booking for my wife...
… I had no help, there was nothing, I ended up writing the letter because I
was so disappointed...
… When I did finally get to see the lady that I spoke to in regards to my
letter of, it was then a letter of complaint, she said to me why didn’t you
come and speak to me and I said I didn’t know your role was there, she was
the acting director of nursing and because you see obviously the first person
you speak to is the nurses they knew that I wasn’t happy...
… What I first got must be like one of those routine letters that they have
ready to send out when someone complains, saying that they will investigate
my complaint, blah, blah….nothing substantial...
…. I told them I didn’t complain earlier because I was too distraught from
the experience. So, I’m yet to receive anything from them....
… In regards to making a complaint I really didn’t know which way to go. I
spoke to a lot of different people and the main information that came back
was for me to get in contact with your local MP which I did...
...My friend... ...she said Participant 9 you do need to make a complaint
about this because this is a terrible situation that could have been not as
severe as it has been. Anyway so I went and I what I did I get a diary and
wrote everything down up until I went to hospital and I went and saw the MP
he was very good and pretty much said to me that unfortunately that because
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of the funding issues and what not the local hospital there is under a lot of
strain and demand on the doctor because it is only a one doctor hospital...
... I remember that in the hospital they did have a pamphlet on if you wanted
to you could contact I am pretty sure it was the Health Quality and
Complaints Commission or it might have been someone else. I actually went
looking for the information because nothing was given to me to fill out. I
don’t think they wanted to encourage me that much I don’t know it was more
Dad, he said there should a pamphlet somewhere in the hospital and it was
in the end from midway in my stay I was getting up and really walking
around and looking at things, wanting to be a bit more active and I started
walking around and you would get in the habit seeing and reading things
around, like the brag wall and on the side there was pamphlet. I didn’t
bother with taking any from the other hospital because it wasn’t that hospital
that I had the issue with it was with hospital XX so when I went there I would
walk around and have a look there and they had a big board with different
pamphlets on different issues whether it was from making a complaint or just
about general patient issues...
...I was considering contacting the Courier-Mail and anyway when I spoke
to the conciliator she said I don’t advise you do that because when you come
to conciliation you come with a sense of good will and going public with
your complaints is not a sense of good will, that’s what I was told and I
thought oh! Okay that’s not really the way I see it...
... I feel like I am constantly writing things down and reliving it...
...When I sent the payment to the Radiology Unit I put a note in there
complaining about the receptionist and the treatment I received. I heard
nothing back from the service...
...Why I really thought long and hard before I sent in the complaint, I
thought was it just me because I was in so much pain? Because normally
when I go there every couple of years for a scan I don’t recall being in pain
during those times, so I was thinking maybe it was because of the way I am
feeling, but my husband was with me the whole time and he said she is not
very good you know, and he wasn’t very happy with the treatment either. His
judgement only reinforced that I wasn’t wrong about the situation because I
was in pain....
... I didn’t receive any acknowledgement; I didn’t make a huge letter I just
made some comments in the paperwork I sent back...
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Appendix Q: Theme 5: Perceptions of Negligence (extract examples)
... I received no help, in fact there was one nurse in particular that I found
very difficult and I blame her for the circumstances surrounding the death of
my wife and I believe that she should be struck off and never be allowed to
work again...
... Her death was preventable and the doctor and nurse involved in her care
should have been subject to disciplinary action...
... I was just so angry and in disbelief, I went to the police station. I went
over to the CIB and said to them that I wanted the nurse and doctor charged
with causing the death of my wife. You know what the police officer said to
me? He said that they can’t charge staff for things that happen in hospital...
... They wrote she was discharged at two thirty in the afternoon, whereas in
fact we went home about eleven thirty, I know this because she wasn’t there
for lunch...
The specialist said point blank that the hospital should have concluded that
my wife had a heart attack and that the likelihood of another one was
probable. One of the specialists actually said that in his opinion my wife was
very badly done by...
...I said I felt like Dad was eighty-six he had a lot of health issues and they
basically kind of like they were just happy to have him just slip away I
honestly I did. I battled for everything...
... If you had watched your son or daughter vomit for the last five weeks how
would you feel, and I said that’s how I feel about my dad, I am really
worried that I am going to take him out of here in a box because nobody,
nobody is listening to me telling everybody that my father is constantly
vomiting they were weighing him each week and he was losing weight I don’t
know why, I don’t know why to this day I can’t figure out why because it is
so hard to try to think perhaps there is a line in the sand that the hospital
draws that says okay we are not going to spend any more money on this
person...
... You know there is saying that says ―doctors bury their dead, no what is it,
and doctors bury their mistakes‖...
... I had my son delivered by Caesarean section which at the time we were
sort of, it was a rushed situation and we gave no consent and we were
definitely not given any information in any way, we sort of were just moved
into a room and we thought at the time that something must have been really
wrong and then after it was all sewn up and everything the doctor came in
and said that he felt that I had been in labour long enough that was his only
reason for the Caesarean...
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... I remember when it first happened actually I remember saying to one of
the nurses at the hospital I can’t believe this happened to me I am not a bad
person...
... Because I felt we were treated badly and I didn’t have the opportunity to
give informed consent and that there was actual no clinical evidence for the
need for the caesarean other than the Doctor thought that I had enough time
which to me is not justifiable for a major operation...
... In the beginning I couldn’t talk about it without bursting into tears and I
guess I also heard other stories in the community about the not very good
maternity care at this hospital.
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Appendix R: Poster—London, UK.
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Appendix S: Oral Presentation—Miami, USA
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Appendix T: Oral Presentation—Molde, Norway
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Appendix U: Oral Presentation—Adelaide, South Australia
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Appendix V: Oral Presentation—Surfers Paradise, QLD
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Appendix W: Confirmation Seminar Notification
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Appendix X: Final Seminar Notification
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Appendix Y: Acceptances for oral/poster presentation but unable to attend
1. Oral Presentation. 23rd
Annual Conference of the European Health
Psychology Society. 23rd-26th September. Pisa, Italy. (abstract submitted:
9/3/09 notified of acceptance: 27/4/09) An exploration of patient’s emotions
and coping strategies when making a complaint about care.
2. Oral Presentation. 15th
Annual Qualitative Health Research Conference.
British Columbia/Vancouver. 4-6th
October 2009. (abstract submitted:
25/2/09 notified of acceptance: 3/7/09) Raising the voice of dissatisfaction:
A qualitative study of the Australian health care consumer and the
experience of complaining.
3. Poster Presentation. The International Society for Quality in Health Care.
Designing for Quality, Ireland/Dublin. 11-14th
October 2009 (abstract
submitted: 25/2/09 notified of acceptance: 11/7/09) The patient’s perspective
on the management of their complaints.
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