Accepted Manuscript

Title: Patient satisfaction: concept analysis in the healthcare

context

Authors: Janet H.Y. Ng, Bronya H.K. Luk

PII: S0738-3991(18)31004-8
DOI: https://doi.org/10.1016/j.pec.2018.11.013
Reference: PEC 6127

To appear in: Patient Education and Counseling

Received date: 30 May 2018

Revised date: 8 October 2018
Accepted date: 17 November 2018

Please cite this article as: Ng JHY, Luk BHK, Patient satisfaction: concept
analysis in the healthcare context, Patient Education and Counseling (2018),
https://doi.org/10.1016/j.pec.2018.11.013

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Patient satisfaction: concept analysis in the healthcare context

Janet H.Y. Ng
The Hong Kong Polytechnic University, Hong Kong

Bronya H.K. Luk

Tung Wah College, Hong Kong

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Janet H.Y. Ng, BSc(Sp&HearSc), MMedSc

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DHSc Candidate, Faculty of Health and Social Sciences, The Hong Kong Polytechnic
University, Hung Hom, Kowloon, Hong Kong, China

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Bronya H.K. Luk, DHSc, MN, BN, RN
Senior Lecturer, School of Nursing, Tung Wah College, 31 Wylie Road, Homantin,
Kowloon, Hong Kong, China

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*
Corresponding author:
Bronya H. K. Luk, School of Nursing, Tung Wah College, 31 Wylie Road, Homantin,
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Kowloon, Hong Kong, China
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E-mail: hkluk@twc.edu.hk
Tel: +852 31906742 / Fax: +852 28721566
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Highlights
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 Patient satisfaction regarded as an indicator of healthcare quality

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 The concept of satisfaction is not unique to healthcare

 Provider attitude, technical competence, accessibility and efficacy

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 Patient compliance, clinical outcomes, loyalty and improve health of users

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Abstract
Objective: Patient satisfaction had been the focus of many scientific studies worldwide.
However, very few studies published had addressed the definition of the concept of
patient satisfaction. Therefore this present concept analysis is to explore the attributes
of the concept in the broader healthcare context.
Methods: The Rodgers method, an inductive method of concept analysis, was selected
to guide this concept analysis.
Results: The attributes of patient satisfaction in the healthcare context identified were
provider attitude, technical competence, accessibility, and efficacy. Perception in
relation to expectation, patient demographics and personality, and market competition
were regarded as prerequisites of patient satisfaction. Consequences of patient
satisfaction identified in this analysis were: patient compliance, clinical outcomes,
loyalty and referrals.
Conclusion: As healthcare is becoming an increasingly competitive marketplace,

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studying patient experience could certainly help practitioners to better encompass
patient perspectives in service delivery and improve patient satisfaction.

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Practice implications: To ensure the validity of patient satisfaction measurement and
subsequently improve healthcare quality, practitioners should involve patients in

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identifying important factors relevant to each attributes of patient satisfaction.

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1. Introduction
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A substantial increase in the interest on patients’ perspective of healthcare delivery
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had been noted during the past decade. Patient satisfaction had been the focus of many
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scientific studies worldwide. Patient satisfaction is regarded as an indicator of

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healthcare quality, though the link between the two domains are far from clear. Patient
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satisfaction surveys had been administered in healthcare organizations worldwide [1–

7]. The first population-wide patient satisfaction survey in Hong Kong was conducted
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among patients discharged from public hospitals in 2010 [8]. More recent studies had

also investigated patient satisfaction in ambulatory settings [9,10] and audiological

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settings [11–13]. However, many of these cross-sectional studies were likely to have

methodological weaknesses. Most study instruments used researcher-defined

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parameters in measuring patient satisfaction. Since the focus of patient satisfaction

should lie upon the patients, using predetermined parameters without inductive

exploration on the underlying values held by patients left the validity of such study

instruments questionable. Moreover, despite widespread use of the term ‘patient

satisfaction’ in researches and the ample availability of study instruments on patient

satisfaction, very few studies published had addressed the definition of the concept of

patient satisfaction. Ambiguity in concept meaning makes it difficult to make

judgement on the empirical value of study instruments. Clarification of the concept of

patient satisfaction, therefore, serves as the pre-requisite for the evaluation of existing

patient satisfaction instruments and the development of valid and reliable instruments

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in the future.

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The concept of satisfaction is not unique to healthcare. In fact, the study on

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satisfaction had been long established in the social sciences discipline. One of the

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earliest discussion on satisfaction of needs was put forward by American psychologist

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Abraham Maslow. In his classical paper, Maslow [14] described, that human needs
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were arranged into a hierarchy of prepotency. He suggested that human needs emerged
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at the fundamental levels of physiological needs and safety needs; yet upon the
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satisfaction of these needs, love needs, esteem needs and the need for self-actualization

would arise at higher levels. He further argued that human being was a perpetually
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wanting animal and hence could rarely reach a state of complete satisfaction. In other
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words, satisfaction is merely an isolated instance along an evolving path of various

needs.
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Though concept analysis on patient satisfaction is still at its infancy, a few papers
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had been published, exploring the concept from different perspectives. The earlier work

by Mahon [15] provided a view on patient satisfaction in relation to contemporary

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nursing care employing both the classical and evolutionary methods. Without providing

details on each attribute, she identified art of care, technical quality of care, access,

finances, physical environment, availability of providers, continuity of care, and

efficacy as the eight defining attributes. Building on Mahon’s [15] work, Wagner and
Bear [16] studied patient satisfaction with nursing care by applying a theoretical

framework of client health behavior. They categorized the attributes of patient

satisfaction as affective support, health information, decisional control, and

professional competencies. Turris [17], instead, presented a feminist analysis on the

concept of patient satisfaction. She attempted to explore the concept away from the

conventional epistemological perspective. Instead of investigating a checklist of

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attributes and formulating satisfaction as a binary concept, she urged for comprehensive

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exploration on the concept in the social context so as to address the uniqueness of

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individual patients and facilitate a deeper understanding of the concept [17]. However,

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none of the previous papers had looked into patient satisfaction in the wider healthcare

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context. Albeit the essential role of nursing in healthcare, it is an undeniable fact that
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healthcare is a highly collaborative profession which demands contributions from
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various disciplines, including medical, nursing, and allied health. The aim of this

present concept analysis is therefore to study the meaning of ‘patient satisfaction’ in the
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broader healthcare context. This systematic scientific inquiry could contribute to the
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knowledge of ‘patient satisfaction’ and help stakeholders in the healthcare industry to

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identify the impact of it.

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2. Methods
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Among concept analysis approaches, methods proposed by Walker and Avant [18]

and Rodgers [19] are frequently used in the healthcare context. Walker and Avant’s
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method is useful for beginner of concept analysis, yet its highly structured steps make

the method too stringent [20]. Also, the method might not be sufficient for concept

clarification due to the absence of theoretical context [21]. In light of Maslow’s

hierarchy of needs [14], patient satisfaction changes over time when needs emerge.
With the advancement of medical technology and availability of information from the

environment, ever-increasing patient expectation is resulted. Viewing patient

satisfaction as an evolving concept, Walker and Avant’s method is therefore considered

unsuitable for the present concept analysis. Rodgers recognized that concepts

developed over time and were influenced by the context [19]. The progressive,

evolutionary method proposed by Rodgers could clarify, describe and explain the

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concept of choice with a robust body of literature [22]. This inductive method of

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concept analysis is therefore selected to guide the present concept analysis on patient

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satisfaction.

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2.1. Data Sources
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The systematic search strategy aims at finding a credible sample relevant to the
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concept under study. A two-phase search strategy was used in this review. During the

first phase, initial database searches were conducted using the keywords ‘patient
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satisfaction’, ‘client satisfaction’, as well as ‘customer or consumer satisfaction’ in

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MEDLINE, CINAHL, Cochrane Database of Systematic Reviews and the PsycINFO

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databases. The searches were limited to papers written in English, peer-reviewed

journals, qualitative studies, quantitative studies, review papers, and published from
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2000 to 2017. These searches yielded 1,735 papers. The second phase search involved
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reviewing the reference lists of all papers retrieved in the first phase to identify

additional papers. Nine papers were identified in the second phase. After removing
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duplicates, the remaining 1,153 papers were further refined by excluding non-English

papers and book chapters. Since patient satisfaction in the healthcare context is the

interest of the present concept analysis, papers discussing job satisfaction, staff

satisfaction, and those beyond the healthcare setting were excluded. A total of 819
papers were excluded, leaving 334 papers’ abstracts for further review. Upon the

retrieval of 153 full-text papers, contents of these papers were reviewed independently

by the two investigators for relevance and applicability to the concept under the present

study. This was to ensure that the study sample was rigorously selected with minimal

researcher bias while obtaining a manageable sample size [19]. Divergent opinions

were thoroughly discussed so as to reach unanimous decision. After review of the 153

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full-text papers, 115 articles were further excluded due to absence of empirical data or

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lack of discussion on patient satisfaction. As a result, 38 papers covering various

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healthcare disciplines were included in further analysis (please refer to Appendix A).

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Details of the stages of search and reasons for exclusion are presented in Figure 1.

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2.2. Quality assessment
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The methodological quality of all selected articles was assessed by the two
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investigators independently. To appraise articles involving qualitative and quantitative

methodologies, the Quality Assessment Tool for Studies with Diverse Designs
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(QATSDD) [23] was used as the quality assessment tool in the present study. The
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QATSDD contains a total of 16 reporting criteria; the 12 criteria applicable to all studies

cover theoretical framework, objectives, setting description, sample sizes and

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representativeness, data collection procedures, rationale for data collection, recruitment

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data, data analysis, user involvement as well as strengths and limitations. Two out of

the 16 items apply to qualitative studies only, and 2 out the 16 items apply to
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quantitative studies only. Each item is measured on a 4-point scale (0=not at all; 1=

very slightly; 2=moderately; 3=complete). Each paper was then given an overall quality

score by summing up the scores of all items. For each article reporting qualitative or
quantitative study, an overall quality score may range from 0 to 42 after appraising 14

applicable criteria.

The overall quality scores of studies included in the present concept analysis range

from 27 to 38. Most studies showed at least moderately strong evidence on criteria

relevant to objectives, setting description, sample sizes and representativeness, data

collection procedures and data analysis. Considering the highest possible score to be

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42, the studies included were found to be of reasonably good quality.

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2.3. Data selection process and analysis

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As discussed earlier, satisfaction of various needs is evolutionary in nature; the

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concept of patient satisfaction should therefore be examined as a dynamic process
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instead of a fixed phenomenon. The advancement of technologies, increased human
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interaction with the environment, and changes in human needs over time would
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certainly influence patient satisfaction. During the process of data collection, coded data

from the literature were categorized into attributes, antecedents, and consequences. To
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prevent premature closure in concept analysis, formal thematic analysis was only
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conducted by the end of data collection. Each category of data was examined and

reorganized to discover themes and trends. Consensus on the selection of attributes,

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antecedents and consequences was supported by theoretical and empirical justifications.

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3. Results
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3.1. Surrogate terms and related concepts

According to Rodgers [19], surrogate terms, which are terms that could be used

interchangeably to express the same concept, must be identified prior to formal data

analysis. During the data collection process, it was found that ‘patient’, ‘client’,
‘customer’ and ‘consumer’ were used interchangeably while discussing their

‘satisfaction’ in the healthcare context. While the four terminologies had been included

in our search strategy, it was later revealed that they were not merely surrogates of one

another. Wing [24] argued that ‘patient’ was the best single term to be used in general

healthcare institutions, though the term ‘client’ may be preferred by service recipients

in the well-person situation such as in prevention, health maintenance and other

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therapeutic settings. As a medical practitioner, he disagreed with the use of the term

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‘client’ as justified by the debate between patient autonomy and medical paternalism

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[24]. He stressed that paternalism was appropriate in professional medical relationships,

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and such practice did not contradict with the practitioner’s respect to patient’s

preferences. Neuberger [25] expressed that the term ‘patient’ implied unequal status
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between health professional and healthcare service recipient as the recipient could only
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play a passive role in the relationship. Deber, Kraetschmer, Urowita, and Sharpe [26]

mentioned that the terms ‘consumer’, ‘customer, and ‘client’ denoted healthcare
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services were commodities to be sold and bought in a market. They further noted that
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healthcare service recipients had developed to engage in partnership and shared

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decision making with health professionals. In view of the evolving nature of the

terminologies, it would be more appropriate to refer ‘client satisfaction’, ‘customer

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satisfaction’ and ‘consumer satisfaction’ as related concepts. It is believed that the

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understanding of the concept of ‘patient satisfaction’ could be enriched through these

related concepts as they serve to provide a more extensive knowledge base for concept
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analysis.

3.2. Attributes
 Attributes are the real definition of a concept found from a rigorous literature-based

analysis, together with the exploration of the contextual aspects of the phenomenon

[19]. The overall finding of the current concept analysis was that the literature is

consistent across studies in its definition of patient satisfaction. The attributes of patient

satisfaction in the healthcare context identified were provider attitude, technical

competence, accessibility, and efficacy.

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3.2.1. Provider attitude

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Attitude is a psychological predisposition of an individual towards a certain

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situation or idea, and it is usually reflected in individual’s behaviors. Among the body

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of literature included in this concept analysis, provider attitude was found to be a
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dimension which had been universally discussed. Patients reported satisfaction when
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they found the providers courteous, friendly, kind, and approachable [27–35]. It was
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also indicated that respect, responsiveness, and individualized attention were important

contributor to patient satisfaction [28,36–41]. A few recent studies highlighted that

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patient satisfaction was also characterized by the providers’ concern to family and
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relatives [30,31,42,43]. Health information plays a vital role in participative decision

making; studies revealed that providers’ information delivery and their involvement of
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the patient in the healthcare processes also affected patient satisfaction across
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disciplines [10,37,38,43–46]. Patient were found to be more satisfied when the

healthcare provider is willing to provide more information and respect patients’

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participation in decision making for the treatment options [47].Provider’s attitude also

influences patient’s participation in the treatment process.

3.2.2. Technical competence

 Technical competence pertained to the technical skills of healthcare

professionals, together with their adherence to high standard. Consistent with previous

concept analysis papers [15,16], technical expertise and professional knowledge

continued to illustrate patient satisfaction in the healthcare context in the present

analysis [32,33,36,37,41,44,48]. Mpinga and Chastonay [43] specifically pointed out

that competent health professionals and appropriate diagnostic and therapeutic

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procedures were key constituents of patient satisfaction. While in the discipline of

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physiotherapy, Hush and colleagues [34] identified that physical therapists’

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professional skills contributed to high patient satisfaction.

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3.2.3. Accessibility
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Accessibility is generally referred to physical location and environment of
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facilities, availability of equipment, appointment arrangement, and access equitability
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to healthcare service. It was demonstrated that hygiene, comfort, and infrastructure of

facilities were found to correlate directly to patient satisfaction [31,36,37,43,48–51].

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Apart from physical factors, systematic factors also have a role to play in healthcare
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accessibility. Waiting time, both for appointment and for procedure during a particular

appointment, was found to be inversely related to patient satisfaction [31,35,43,52–55].

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Furthermore, more recent literature suggested that the availability of healthcare

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providers for consultations of longer duration could increase patient satisfaction

[10,29,30,44–46].
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3.2.4. Efficacy

Efficacy denotes the outcomes in improving or maintaining health status. Patient

satisfaction was more probable to occur when treatments were considered efficacious
[29,39,46,53,56]. Findik and colleagues [32] explicitly identified that duration of

hospitalization could affect patient satisfaction with nursing care. On the other hand,

while examine satisfaction with general anesthesia care, it was revealed that pain

management was a key factor relating to adult patients’ satisfaction [35].

3.3. Antecedents

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Antecedents are phenomena that take place prior to the occurrence of the concept.

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Considering that patient satisfaction is an evolving concept in the healthcare context, it

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is essential to understand that a number of personal and environmental variables pose

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influences on the occurrence of patient satisfaction. The current concept analysis

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identified that perception in relation to expectation, patient demographics and
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personality, as well as market competition were regarded as prerequisites of patient
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satisfaction.
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3.3.1. Perception in relation to expectation

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Merkouris, Ifantopoulos and Lemonidou [57] described that patient satisfaction

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would appear when experiences, expectations and needs perceived were combined.

Johansson and colleagues [48] further illustrated patient satisfaction as the degree of
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convergence between the subjective evaluation of the patients’ cognitive and emotional
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reactions and their expectations regarding ideal nursing care. Many studies shared the

same view on this intrinsic cognitive appraisal and affective response

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[10,30,51,58,31,32,37–39,43,44,46]. Geberemichael and colleagues [53] described that

patients’ expectation on clinical outcomes significantly affected overall patient

satisfaction. It was evident that expectations were principally based on prior experience
with healthcare service [29,36,48]. Expectation was suggested to be inversely related

to satisfaction [34].

3.3.2. Patient demographics and personality

Demographic characteristics and personality traits of patients had been reported

consistently as antecedents of patient satisfaction in the healthcare context

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[29,32,62,36,37,44,50,56,59–61]. Human beings are unique, complex, and dynamic

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composites of demographic characteristics, emotion, personality, social influences, and

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motivation. These components jointly and independently serve to ultimately influence

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patient’s health belief, perceptions, and judgments [44]. For instance, older patients

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tended to have higher patient satisfaction than younger patients [10]. In two studies
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investigating patient satisfaction in outpatient physiotherapy settings [34,63], it was
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found that female patients were more satisfied with the physiotherapy they received.
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Agosta [44] argued that personality traits was a prominent component influencing

patients’ health behavior and perceptions.

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3.3.3. Market competition

Healthcare is considered to be a competitive marketplace as patients nowadays

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play their role as customers and consumers [48]. With increasing demand from
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institutions and the public, as well as the popularity of information dissemination via

the internet, the healthcare market had generally developed greater transparency in
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recent years. Hekkert and colleagues [60] stated that with increasing utilization of

patient satisfaction surveys as a benchmarking instrument among hospitals, patients

could make informed choice on healthcare providers. They further indicated that, with

the introduction of more competition among healthcare insurers, insurers had no choice
but to demand quality in the healthcare service they paid for. Such a competitive market

environment facilitated patient satisfaction to be a key to maintain market share.

Coincidentally, Lei and Jolibert [58] pointed out that hospitals were operating in a

complex and uncertain environment with increased competition and changing

consumer attitude. Satisfying the needs and desires of patients had become an important

strategy for survival in the healthcare market.

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3.4. Consequences

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Consequences are the result of the practical use of a concept in a situation. Various

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researchers had discussed a number of consequences of patient satisfaction. Better use

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of the healthcare system and improved health outcomes had been reported in situations
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where patients were satisfied. Satisfied patients tended to return to the healthcare
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facility more frequently in case of needing healthcare [48]. Garman and colleagues [64]
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mentioned that satisfied patients were more likely to adhere to treatment

recommendations and return for follow up consultations. Studies reported that patient
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satisfaction promoted compliance with treatment regimens [33,44]. It was also found
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that satisfied patients had shorter hospital stays as they were more responsible for their

health conditions [41]. Moreover, satisfied patients tended to recommend the healthcare
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provider to others [48,60]. Lei and Jolibert [58] regarded this word-of-mouth effect as
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an indicator of patient loyalty. Other non-health consequences of patient satisfaction

includes decreased intention to change provider [46,59] and less malpractice litigation
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[29,40]. In addition, patient satisfaction could lead to more appropriate use of the

healthcare system, reducing attrition rates and more importantly, improve the health of

users [27].
3.5. Exemplar

To illustrate the concept of patient satisfaction in the healthcare context, a generic

exemplar had been identified through field observation:

Johnson is a recent stroke survivor who is experiencing moderate problems with memory, word-

finding and right limb weaknesses. Upon discharge from the hospital, he was arranged weekly

therapeutic sessions at a government-funded Day Rehabilitation Centre located near the

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residential complex where he lived. During his first visit to the Day Rehabilitation Centre, Mary,

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the Nursing Officer, introduced the comprehensive rehabilitation program offered by the Centre.

Johnson discussed his worries regarding his recovery and the potential to return to work; Mary

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addressed Johnson’s worries and encouraged him to stay positive to strive for optimal

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rehabilitation results, during the spontaneous recovery phase in particular. Mary also suggested

active involvement of Johnson’s wife in the rehabilitation program. Johnson met the Centre’s

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physiotherapist, occupational therapist, and speech therapist during his subsequent therapeutic
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sessions at the Centre. The therapists always demonstrated courteous and supportive manner
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while employing state-of-the-art devices in the treatment sessions. All sessions were well
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documented and Johnson was made known of his rehabilitation progress regularly. After six

months’ of rehabilitation, Johnson found his memory and word-finding problems significantly
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improved though weakness on his right arm persisted. Johnson was pleased with the services

provided by the Day Rehabilitation Centre and he told Mary that he will continue attending
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therapeutic sessions there.

Though construction of borderline case and contrary case was not an integral part of
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concept analysis using the Rodgers method, it is believed that cases are useful in
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illustrating what the concept is versus what it is not [65]. A borderline case and a

contrary case were therefore constructed and attached in Appendix B.

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4. Discussion and Conclusion

4.1 Discussion
 This concept analysis helps to clarify the meaning of patient satisfaction in the

healthcare context. It has been demonstrated that different healthcare disciplines,

including medical, nursing, physiotherapy and occupational therapy, shared universal

attributes of patient satisfaction. The four attributes of patient satisfaction identified

could be separated into two dimensions. The human dimension covers provider attitude

and technical competence while the system dimension covers accessibility and efficacy.

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Taking a closer look at the human dimension in healthcare, one may be directed to

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explore the relationship between job satisfaction and behavior. Certainly, that is beyond

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the scope of the current study. However, since relationship is not always uni-directional,

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it would be logical to ask: would patient satisfaction in turn affect the behavior of

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healthcare providers and subsequently affect substantial aspect of certain attributes of

patient satisfaction? Synthesizing this concept analysis with Maslow’s [14] discussion
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on satisfaction of needs, it would be impossible to refute his idea that satisfaction is
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only an isolated instance along an evolving path of needs.

Both the human and system dimensions of each defining attributes are dynamic and
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contextual in nature. The complex nature of these dimensions places each attributes into
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different levels of the earlier discussed hierarchy of prepotency. For instance, in the

attribute of provider attitude, one could argue that health information and
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responsiveness are fundamental safety needs of patients, while friendliness could be

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referred to love need; respect and participative consultation could be projected as

esteem needs. Viewing Maslow’s hierarchy of needs as a continuum, it would be easy

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to understand that higher and lower levels of needs are not conflicting with each other,

and one can always achieve certain degree of relative satisfaction [14] at each level. If

this is the case, patient satisfaction should be viewed as a process instead of an outcome

in the healthcare system. Besides, as most patient satisfaction instruments appeared to

measure patients’ perception on certain pre-designed parameters at certain points of

time, it would be more appropriate to refer such instruments as tools measuring patient

experience instead of patient satisfaction.

In fact, patient satisfaction surveys at present are popular tools in understanding

how people and facilities of a healthcare system behave. However, practitioners should

interpret the results of such surveys with care. Since most of the patient satisfaction

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instruments can only provide cross-sectional data on selected parameters and

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participants in most retrospective studies were self-selected, the predictive value of the

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results is considered as methodologically weak. Validity, reliability, and bias should be

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better addressed in future studies. The present concept analysis found that attributes of

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patient satisfaction were generally congruent across healthcare disciplines.
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Notwithstanding, healthcare is considered a broad context, the relative importance of
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the four satisfaction attributes across disciplines remains unknown. Future discipline-,
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setting- or condition-specific research is therefore needed to further understand the

dynamic concept of patient satisfaction. Additionally, scientific inquiry into the

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interaction effect of satisfaction attributes would be helpful for stakeholders in the

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healthcare industry to configure activities for better outcomes.

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4.2 Conclusion
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Clearly, the present concept analysis using the Rodgers method would not be able

to endorse a final concept of patient satisfaction in the healthcare context. However, the
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knowledge obtained from this systematic inquiry could serve as a critical foundation

for further studies and facilitate further knowledge development among healthcare

practitioners. As revealed in this analysis, the unique characteristics of patients, or

perpetually wanting animals as referred by Maslow, made satisfaction a complex,

subjective, multi-faceted concept. As healthcare is becoming an increasingly

competitive marketplace, studying patient experience could certainly help practitioners

to better encompass patient perspectives in service delivery and improve patient

satisfaction. Albeit different in nature, healthcare should not be totally detached from

other industries in the society. While some industries are moving forward to improve

customer orientation in organizations, it would be vital for healthcare practitioners to

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maintain alertness in modifying behaviors according to the ever-changing patient

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expectation.

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4.3 Practice implications

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This concept analysis revealed that patient satisfaction is a complex concept. Such
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complexity makes it difficult to embody the concept comprehensively in instruments
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intending to measure patient satisfaction. Though increasing focus on patient
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satisfaction from all stakeholders may produce positive impact on quality improvement

in healthcare, the use of patient satisfaction surveys results from benchmarking to pay-
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for-performance may produce unintended consequences. It is therefore important for

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healthcare practitioners to scrutinize the design and use of patient satisfaction surveys.

To ensure the validity of instruments and subsequently improve healthcare quality,

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practitioners should involve patients in identifying important factors relevant to both

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the human and system dimensions of each attributes of patient satisfaction.

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Authors’ contribution:
The authors’ contributions are as follows. JN and BL carried out the study conception
and design. JN and BL conducted the searches and data collection. JN and BL worked
together to analysis and interpret data. JN drafted the manuscript. BL critical revised
the manuscript for important intellectual content. All authors read and approved the
final manuscript.
Conflicts of interest:
The authors have no competing interests to declare

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SC
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N
A
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TE
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CC
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 Records identified Additional records identified
through database searching through other sources
(n=1,735) (n=9)

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Records after duplicated removed
(n=1,153)

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SC
Records excluded
(n=819)
Non-English
Book chapter
Records abstract
screened (n=334) U Job satisfaction
Staff satisfaction
Unrelated to healthcare
N
A

Non full-text excluded

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(n=181)
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Full-text articles
assessed for eligibility
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(n=153)

Irrelevant excluded
after discussion among
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investigators (n=115)

Studies included in
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concept analysis
(n=38)
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Figure 1 Summary of the search strategy