Our exploratory study is the first to link elective information acquisition, hospital choice decision making, WOM communication frequency and communication channels as a function of satisfaction for elective, smaller operations. Our patients had used mainly experienced based sources during the decisive process with information from their GP / specialist doctor ranking first, followed by family/friends. WOM distribution followed the routine contact frequency in hospital and after discharge. In hospital, nurses and non-medical personnel were contacted most frequently, post discharge family/friends. About 40% were satisfied and would recommend the hospital, while of the 13% dissatisfied only 46.6% would recommend the hospital to family/friends. Overall, positive WOM dominated, satisfied patients had given rather positive than negative (ratio 11.6: 1) but dissatisfied more negative (ratio 1:1.2) information to others.
Patients independently use various sources for the choice of the hospital, they make particularly use of the WOM concept that is based on trust and experience. [1, 3, 4, 2] What’s new is that the most common way of passing on the hospital experience is by talking to family and friends, the GP/specialist and the hospital staff in analogy to the contact frequency. Overall, positive WOM communication predominates while there are major differences between satisfied and dissatisfied patients.
The most commonly used sources for hospital choice in our study are consistent with previous surveys of planned [4] or actually used information sources.[1]
However, patients in our study relied mainly on information from the GP/specialist followed by the reputation of the hospital. The reason might be that the implementation of our study at two maximum care facilities.
Depending on the sources of information, experience-based information did have the major impact in the decision-making process, often with inclusion of additional medical expertise.
The assumption that patients would communicate satisfaction in analogy to the decision-making process may only be confirmed in terms of the experience-based sources, although the conditions seem reversed, were significantly more patients used the advice of the GP/specialist as a primary source but had postoperatively communicated more often with family and friends. This does not come as a surprise given that the groups of people that patients routinely make contact to after hospital discharge are the ones who appear to receive most information. Given this, the contact frequency to family and friends naturally was highest, followed by non-medical clinic personnel and the hospital doctors, GPs as well as specialists.
The communication about different aspects of the treatment starts in hospital, were patients stated to frequently have informed hospital personnel about their experiences. Here, it is possible to assess satisfaction aspects at an early stage and on-site, in order to identify quality-relevant deficiencies and to implement appropriate measures. [3] Furthermore, at this stage, management of dissatisfaction may impact on post discharge WOM behavior.
These are important findings, since hospitals have little impact on WOM after discharge and interventions concerning aspects of satisfaction may be initiated early and in hospital.
Feedback in social networks or on websites may account for up to 18% of communication,[34] in our study only two patients used this possibility to give positive feedback. It may be that the Internet use takes place later than in our investigated period, or that the operations under investigation are not distributed frequently over the Internet.[2] Overall, dissatisfied patients choose similar ways for communication as satisfied ones.
We have found lower satisfaction in patients with persistent pain or a slow recovery to normal function, two indicators of abnormal healing processes. Preoperative fatigue may alter patients’ expectations and therefore exert impact on satisfaction in our study.
Satisfaction and dissatisfaction can be considered different constructs, the “two-factor theory’’.[35] Within this concept, some facets of the care produce satisfaction, while other facets produce dissatisfaction, even in the same patient. This effect has been described using satisfaction questionnaires, were neither of the questionnaires reported total satisfaction nor dissatisfaction. [36, 32, 28]
The theory on asymmetrical effects suggests that negative events produce a stronger effect by signalling that action needs to be taken and proportionally more dissatisfied people are expected to engage in WOM. [37] Our findings suggest otherwise and most patients stated that they had passed on positive aspects of their stay and treatment, and satisfied patients reported a higher contact frequency. Several factors may be responsible: First, most patients are thankful when surgery and anesthesia are over. In addition, it is unusual address negative or unpleasant factors directly, as long as the patients are not extremely dissatisfied.[38] Here, the so-called social desirability may influence behavior, while there are further studies that support our findings: in the ‘‘Polyanna principle’’, pleasantness predominates and positive aspects are more accessible after exposition to pleasant events (‘‘positivity bias’’). Individuals strive for interpretation in positive terms to minimize negative aspects, in extreme cases leading to denial. [37]
There might a negative association in the lower and a positive in the higher part of the satisfaction continuum as in our study. In this concept, the relationship changes at a point located within a “zone of indifference”, [39] were expectations and experiences match and no particular reaction is to be expected., an effect that was observable in our study. [40]
Hence, WOM communication itself cannot be considered as an indicator of the degree of satisfaction. [2]
The degree of satisfaction was determined in analogy to previous studies by means of the mean and the SD.[28, 29] Even though other classifications could be feasible, all satisfied respondents of our study would recommend the hospital, in the group of dissatisfied this was only 46% while considering WOM communication, we found a ‘zone of indifference’, [39] supporting the structure of the study.