Chapter 1: Overview of the Study · Phenomenological Analysis (IPA) approach, guided by the philosophical influences of Heidegger (1889-1976). As part of the interpretive endeavour

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

http://www.healthcare-events.co.uk/conf/booking.php?action=home&id=327

http://www.healthcare-events.co.uk/conf/booking.php?action=home&id=327

http://www.aachonline.org/programs/internationalconference/

http://search.conduit.com/Results.aspx?q=Phenomenological&SearchSourceOrigin=10&hl=en&SelfSearch=1&ctid=CT2405725

http://www.himolde.no/index.cfm?pageID=2416

http://www.achs.org.au/FriPresentations/#3551

http://www.achse.org.au/frameset.html

iii

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

v

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.

vi

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

vii

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

viii

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

ix

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

xi

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

xii

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

xiii

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


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.


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'


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‖


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


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


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


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


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


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


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.


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


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


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


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)


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


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


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.


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

http://www.austlii.edu.au/au/legis/nsw/consol_act/pha1991126/


19


State/

Territory

Governing

Body

Governing

Act


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


20


State/

Territory

Governing

Body

Governing

Act


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;


21


State/

Territory

Governing

Body

Governing

Act


(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;


22


State/

Territory

Governing

Body

Governing

Act


(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).


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.


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.


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.


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


27




Owner if

applicable



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


28




Owner if

applicable



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.


29




Owner if

applicable



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


30




Owner if

applicable



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.


31




Owner if

applicable



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


32




Owner if

applicable



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


33




Owner if

applicable



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


34




Owner if

applicable



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.


35




Owner if

applicable



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



61 Mothers in region. √ Survey, group consultations re: Hospital and tests conducted

in pregnancy.

1 1989 SA



60 (mainly consumers) Mothers and some health

workers in region. √ Public meeting Re: Hospital care during pregnancy and

birth.


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


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.


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


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


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


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


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


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


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


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


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


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


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


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


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


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.


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


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


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


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


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


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


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.


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


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


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- )


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).


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.


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


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


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.


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

http://www.phenomenologyonline.com/inquiry/1.html


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,


69

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


70

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.


71

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.


72

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


73

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.


74

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


75

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).


76

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


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


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


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)


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.


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)


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)


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


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


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.


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


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


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.


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


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


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

http://www.complaints-study.org/


92

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


93

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:


94

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


95

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


96

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.


97

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.

Chapter 4: Findings

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 - ).

Chapter 4: Findings

99

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

Chapter 4: Findings

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%)

Chapter 4: Findings

101

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%)

Chapter 4: Findings

102

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

Chapter 4: Findings

103

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

Chapter 4: Findings

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

Chapter 4: Findings

105

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

Chapter 4: Findings

106

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

Chapter 4: Findings

107

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

Chapter 4: Findings

108

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:

Chapter 4: Findings

109

(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

Chapter 4: Findings

110

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?

Chapter 4: Findings

111

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

Chapter 4: Findings

112

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

Chapter 4: Findings

113

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.

Chapter 4: Findings

114

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

Chapter 4: Findings

115

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

Chapter 4: Findings

116

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,

Chapter 4: Findings

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.

Chapter 4: Findings

118

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

Chapter 4: Findings

120

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...

Chapter 4: Findings

121

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

Chapter 4: Findings

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

Chapter 4: Findings

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...

Chapter 4: Findings

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

Chapter 4: Findings

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

Chapter 4: Findings

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

Chapter 4: Findings

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

Chapter 4: Findings

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

Chapter 4: Findings

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

Chapter 4: Findings

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

Chapter 4: Findings

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

Chapter 4: Findings

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








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








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





Chapter 4: Findings

135






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








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







Perception of negligence


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









Chapter 4: Findings

136



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








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









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









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




Chapter 4: Findings

137



left to my own devices.

I had to ask for pain relief, no-one

really cared enough to listen





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








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








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









Chapter 4: Findings

138



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.








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?









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).


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


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


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


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


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


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


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


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


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


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.


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


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.


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...


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


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.


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...


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


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.


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


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.


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


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.


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:


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).


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


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


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.


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


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


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?


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


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.


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,


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.


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


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


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


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


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.


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.


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


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.


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


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


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


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.


6.4.1.2.1 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


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.


187


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.


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).


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


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).

.


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


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.


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

194

Reference List

ACT Government. (2010). A Local Hospital Network for the Australian Capital

Territory—A discussion paper on implementing the National Health and

Hospitals Network Agreement. Retrieved from

http://www.health.act.gov.au/c/health?a=sendfile&ft=p&fid=128892639

7&sid

Alfred, A., & Munro, B. (2008). Open disclosure: a review of the literature.

Retrieved from http://www.psychology.ecu.edu.au

Allan, J., Schattner, P., Stocks, N., & Ramsay, E. (2009). Does patient

satisfaction of general practice change over a decade? BMC Family

Practice, 10 (13), doi: 10.1186/1471-2296-10-13.

AMEX-SOCAP. (1995) Study of consumer complaint behaviour in Australia.

Retrieved from: http://www.socap.org.au/

Anderson, K., Allan, D., & Finucane, P. (2000). Complaints concerning the

hospital care of elderly patients: a 12-month study of one hospital‘s

experience. Age and Ageing, 29(5), 409-412.

Anderson, K., Allan, D., & Finucane, P. (2001). A 30-month study of patient

complaints at a major Australian hospital. Journal of Quality in Clinical

Practice, 21(4), 109-111.

Ang, L., & Buttle, F. (2006). Customer retention management processes: A

quantitative study. European Journal of Marketing, 40(1/2), 83-99.

http://www.health.act.gov.au/c/health?a=sendfile&ft=p&fid=1288926397&sid

http://www.health.act.gov.au/c/health?a=sendfile&ft=p&fid=1288926397&sid

http://www.psychology.ecu.edu.au/

http://www.socap.org.au/

Reference List

195

Annells, M. (1996). Hermeneutic phenomenology: philosophical perspectives

and current use in nursing research. Journal of Advanced Nursing, 23(4),

705-713.

Arnold, E.C., & Boggs, K. U. (2007). Interpersonal relationships: Professional

communication skills for nurses. (5th

Ed.). Saunders, Elsevier.

Australian Commission on Safety and Quality in Health Care (2010),Windows

into Safety and Quality in Health Care 2010, ACSQHC, Sydney.

Australian Standard™ Customer satisfaction—Guidelines for complaints

handling in organizations (ISO 10002:2004, MOD), (2006).

Bagozzi, R. P., Gopinath, M., & Nyer, P. U. (1999). The role of emotions in

marketing. Journal of the Academy of Marketing Science, 27(2), 184-

206.

Bark, P., Vincent, C., Jones, A., & Savory, J. (1994). Clinical complaints: a

means of improving quality of care. Qualitative Health Care, 3(3), 123-

132.

Beach, M. C., Sugarman, J., Johnson, R. L., Arbelaez, J. J., Duggan, P.S, &

Cooper, L. A. (2005). Do patients treated with dignity report higher

satisfaction, adherence, and receipt of preventive care? Annals of Family

Medicine, 3(4), 331-338.

Bendall, D., & Powers, T. L. (1995). Cultivating loyal patients. Journal of

Health Care Marketing, 15(4), 50-53.

Reference List

196

Bendall-Lyon, D., & Powers, T. L. (2001). The role of complaint management in

the service recovery process. Joint Commission Journal on Quality and

Patient Safety, 27(5), 278-86.

Best, M., & Neuhauser, D. (2004). Avedis Donabedian, father of quality

assurance and poet. Journal of Quality and Safety Healthcare. 13, 472-3.

Blomberg, C. (1996). The professional indemnity review: what did it

accomplish? Medical Journal of Australia, 164(8), 502-504.

Blumenberg, L. (2003). Patients as consumers and advocates. Retrieved from

http://thyroid.about.com/library/news/bladvocate.htm

Bodey, K., & Grace, D. (2006). Segmenting service ―complainers‖ and ―non-

complainers‖ on the basis of consumer characteristics. Journal of

Services Marketing, 20(3), 178-187.

Bova, C., Fennie, K. P., Watrous, E., Dieckhaus, & K., Williams, A. B. (2006).

The health care relationship (HCR) trust scale: Development and

psychometric evaluation. Research in Nursing & Health, 29(5), 477-488.

Brouwer, G. E. (2007). Good practice guide to complaint handling for Victorian

public sector agencies: Victorian Ombudsman.

Burnard, P., & Gill, P. (2009). Culture, communication and nursing. Pearson

Education Limited.

http://thyroid.about.com/library/news/bladvocate.htm

Reference List

197

Carmel, S. (1988). Hospital patients‘ responses to dissatisfaction. Sociology of

Health and Illness, 10(3), 262-281.

Chebat, J. C., Davidow, M., & Codjovi, I. (2005). Silent voices: Why some

dissatisfied consumers fail to complain. Journal of Service Research:

JSR, 7(4), 328-342.

Chulmin, K., Sounghie, K., Subin, I., & Changhoon., S. (2003). The effect of

attitude and perception on consumer complaint intentions. Journal of

Consumer Marketing, 20(4), 352-371.

Cocozza Martins, D. (2008). Experiences of homeless people in the health care

delivery system: A descriptive phenomenological study. Public Health

Nursing, 25(5), 420-430.

Cohen, D. J., & Crabtree, B. F. (2008). Evaluative criteria for qualitative

research in health care: controversies and recommendations. Annals of

Family Medicine 6:331-339.

Cohen M.Z, Kahn, D.L., & Steeves, R.H. (2000). Hermeneutic phenomenology

research: A practical guide for nurse researchers. London: Sage

Publications.

Commonwealth of Australia. (2010). A National Health and Hospitals Network

for Australia’s Future—Delivering better health and better hospitals.

Retrieved from

Reference List

198

http://www.health.gov.au/internet/yourhealth/publishing.nsf/Content/rep

ort-redbook/$File/HRT_report3.pdf

Cooper, D., & Jenkins, A. (1999). Obtaining consumer feedback from clients of

home based care services: A review of the literature. (Working paper no.

21): Australian Institute of Health and Welfare, Canberra.

Creswell, J. W. (2003). Research design: Qualitative, quantitative, and mixed

methods approaches (Second ed.) Thousand Oaks, CA: Sage

Publications.

Customer complaints, it's still a business. (2005). Retrieved from

http://www.docstoc.com/docs/29091194/Customer-Complaints.

Daniel, A. E., Burn, R. J., & Horarik, S. (1999). Patients‘ complaints about

medical practice. Medical Journal of Australia, 170(12), 598-602.

Davidow, M. (2003). Organizational responses to customer complaints: What

works and what doesn‘t. Journal of Service Research, 5(3), 225-250.

Davis, B. A., & Duffy, E. (1999). Patient satisfaction with nursing care in a rural

and urban emergency department. Australian Journal of Rural Health,

7(2), 97-103.

http://www.docstoc.com/docs/29091194/Customer-Complaints-%E2%80%93-Its-still-a-people-business

Reference List

199

Dealey, C (2003). Living with a pressure ulcer: A study progress report.

European Pressure Advisory Panel. Retrieved from

http://epuap.org/review6_1/page8.html

Deming, W. E. (1986). Out of the crisis. Cambridge, MA: Massachusetts

Institute of Technology, Center for Advanced Educational Study.

Denzin, N. K., & Lincoln, Y. S. (2005). (Eds.). The sage handbook of qualitative

research. (3rd

ed.). Midlands: Sage Publications.

De Witt, L., & Ploeg, J. (2006). Critical appraisal of rigour in interpretive

phenomenological nursing research. Journal of Advanced Nursing, 55(2)

215-229.

Dixon-Woods, M., Shaw, R.L., Agarwal, S., & Smith, J.A. The problem of

appraising qualitative research. Journal of Quality and Safety in Health

Care, 13, 223-225.

Doig, G. (2004). Responding to formal complaints about the emergency

department: Lessons from the service marketing literature. Emergency

Medicine Australasia, 16(4), 353-360.

Donabedian, A. (1966). Evaluating the quality of medical care. Milbank

Memorial Fund Quarterly: Health and Society, 44(3; pt. 2) 166-203.

Reference List

200

Donabedian, A. (1992). Quality assurance in health care: consumers‘ role.

Quality in Health Care, 1(4), 247-251.

Douglas, D., & Harrison, R. D. (1996). Turning around patient complaints in a

regional hospital. Australian Health Review, 19(3), 126-137.

Dowling, M. (2004). Hermeneutics: an exploration. Nurse Researcher, 11(4),

30-39.

Draper, M., & Hill, S. (1995). The role of patient satisfaction surveys in a

national approach to hospital quality management. Canberra: Australian

Government Publishing Services.

Draper, M. (1997). Involving consumers in improving hospital care: lessons

from Australian hospitals. Canberra: Commonwealth Department of

Health and Family Services.

Dreyfus, H. L. (1999). The primacy of phenomenology over logical analysis: A

critique of Searle. Philosophical Topics, 27(2), 3-24.

Ekwall, A., Gerdtz, M., & Manias, E. (2008). The influence of patient acuity on

satisfaction with emergency care: perspectives of family, friends and

carers. Journal of Clinical Nursing, 17(6), 800-809.

Fahie, V.P. (1994). Triangulation: Measurement issues and solution exploration.

The ABNF Journal, 5(5), 138-141.

http://socrates.berkeley.edu/~hdreyfus/rtf/Primacy_Critique_Searle_11_99.rtf

http://socrates.berkeley.edu/~hdreyfus/rtf/Primacy_Critique_Searle_11_99.rtf

Reference List

201

Fallon, A., Gurr, S., Hannan-Jones, M., & Bauer, J. D. (2008). Use of the acute

care hospital foodservice patient satisfaction questionnaire to monitor

trends in patient satisfaction with foodservice at an acute care private

hospital. Nutrition & Dietetics, 65(1): 41- 46.

Finney Lamb, C. E., Boers, M., Owens, A., Copeland, J., & Sultana, T. (2008).

Exploring experiences and attitudes about health care complaints among

pregnant women, mothers and staff at an opioid treatment service.

Australian Health Review, 32(1), 66-75.

Findlay, L. (2009). Debating phenomenological research methods.

Phenomenology and Practice, 3(1), 6-25.

Fletcher, M. (2000). The quality of Australian health care: Current issues and

future directions. Occasional Papers Health Financing Series, Vol 6.

Prepared for the Commonwealth Department of Health and Aged Care,

Canberra. Retrieved from

http://www.health.gov.au/internet/main/publishing.nsf/Content/C269666

C4E4804A5CA25749800259350/$File/ocpahfsv6.pdf.

Folkman, S., Lazarus, R. S., Dunkel-Schetter, C., DeLongis, A., & Gruen, R. J.

(1986). Dynamics of a stressful encounter: Cognitive appraisal, coping,

and encounter outcomes. Journal of Personality and Social Psychology,

50(5), 992-1103.

http://www.health.gov.au/internet/main/publishing.nsf/Content/C269666C4E4804A5CA25749800259350/$File/ocpahfsv6.pdf

http://www.health.gov.au/internet/main/publishing.nsf/Content/C269666C4E4804A5CA25749800259350/$File/ocpahfsv6.pdf

Reference List

202

Ford, G. (2001). Measuring consumer feedback: Examples of patient surveys in

Australian public hospitals. Health Issues, 68, 21-25.

Friele, R. D., & Sluijs, E. M. (2006). Patient expectations of fair complaint

handling in hospitals: empirical data. BMC Health Services Research, 6,

(106).

Friele, R. D., Sluijs, E. M., & Legemaate, J. (2008). Complaints handling in

hospitals: an empirical study of discrepancies between patients‘

expectations and their experiences. BMC Health Services Research, 8

(199).

Frijda, N. (1986). The emotions: Studies in emotion and social interaction. New

York: Cambridge University Press.

Gal, I., & Doron, I. (2007). Informal complaints on health services: hidden

patterns, hidden potentials. International Journal for Quality in Health

Care, 19(3), 158-163.

Garrett, P.W., Dickson, H. G., Young, L., & Klinken Whelan, A. (2008). The

happy migrant effect: perceptions of negative experiences of healthcare

by patients with little or no English: a qualitative study across seven

language groups. Quality and Safety in Health Care, 17(2), 101-103.

Reference List

203

Gilly, M. C., Stevenson, W. B., & Yale, L. J. (1991). Dynamics of complaint

management in the service organization. The Journal of Consumer

Affairs, 25(2), 295-323.

Gilmour, P., & Hunt, R. A. (1998). Total quality management: Integrating

quality into design, operations and strategy. Corporate Insight

Publishing Pty Ltd.

Giorgi, A. (1997). The theory, practice, and evaluation of the phenomenological

method as a qualitative research procedure. Journal of Phenomenological

Psychology, 28(2), 235-260.

Giorgi, B. (2005). Reflections on therapeutic practice guided by a Husserlian

perspective. Journal of Phenomenological Psychology. 36(2), 141-195.

Glass, N. (2010). Interpersonal relating: health care perspectives on

communication, stress and crisis. (1st Ed.). Palgrave Macmillan.

Gregory, J. (2006). Conceptualising consumer engagement: A review of the

literature. Australian Institute of Health Policy Studies. Retrieved from

http://healthpolicystudies.org.au/component/option,com_docman/task,cat

_view/gid,55/Itemid,145/

Gullickson, C. (1993). My death nearing its future: A Heideggarian

hermeneutical analysis of the lived experience of persons with chronic

illness. Journal of Advanced Nursing.18 (9), 1386-1392.

http://healthpolicystudies.org.au/component/option,com_docman/task,cat_view/gid,55/Itemid,145/

http://healthpolicystudies.org.au/component/option,com_docman/task,cat_view/gid,55/Itemid,145/

Reference List

204

Health and Community Services Complaints Act (1998). Northern Territory of

Australia: Department of Justice. Retrieved from

http://www.hcscc.nt.gov.au/resources/legislation-code/

Health and Community Services Complaints Act (2004). South Australia:

Legislative Assembly. Retrieved from

http://www.austlii.edu.au/au/legis/sa/consol_act/hacsca2004413/

Health and Disability Services (Complaints) Act (1995). Act No 075. Western

Australia: Legislative Assembly. Retrieved from

http://www.slp.wa.gov.au/legislation/statutes.nsf/main_mrtitle_415_hom

epage.html

Health Care Complaints Act (1993). Act No 105. New South Wales: Legislative

Assembly. Retrieved from

http://www.legislation.nsw.gov.au/viewtop/inforce/act+105+1993+FIRS

T+0+N/

Health Complaints Act (1995). Act No 95. Tasmania: Legislative Assembly.

Retrieved from

http://www.austlii.edu.au/au/legis/tas/consol_act/hca1995181/

Health Quality and Complaints Commission Bill (2006). Act No. 25.

Queensland: Legislative Assembly. Retrieved from

http://www.legislation.qld.gov.au/LEGISLTN/ACTS/2006/06AC025.pdf

http://www.hcscc.nt.gov.au/resources/legislation-code/

http://www.austlii.edu.au/au/legis/sa/consol_act/hacsca2004413/

http://www.legislation.nsw.gov.au/viewtop/inforce/act+105+1993+FIRST+0+N/

http://www.legislation.nsw.gov.au/viewtop/inforce/act+105+1993+FIRST+0+N/

http://www.legislation.qld.gov.au/LEGISLTN/ACTS/2006/06AC025.pdf

Reference List

205

Health Services (Conciliation and Review) Act (1987) Act No, 25, Version No.

047. Victoria: Legislative Assembly. Retrieved from

http://www.legislation.vic.gov.au/

Health Community Council, Handbook. (2008). Queensland Government.

Retrieved from

http://www.health.qld.gov.au/hcc/docs/hcc_guidelines_web.pdf

Health Consumers Queensland….your voice in health. (2010). Retrieved from

http://www.health.qld.gov.au/hcq/publications/PtnCentreCare.pdf

Health Practitioner Regulation National Law Bill (2009). Retrieved from

http://www.aph.gov.au/Library/pubs/bd/2009-10/10bd132.pdf

Healy, J., & Braithwaite, J. (2006). Designing safer health care through

responsive regulation. Medical Journal of Australia, 184(10), S56-S59.

Heath, A. (1997). The proposal in qualitative research. The Qualitative Report,

3(1). Retrieved from http://www.nova.edu/ssss/QR/QR3-1/heath.html

Heidegger, M. (1962). Being and Time. (J. Macquarrie & E. Robinson, Trans.

San Francisco: Harper & Row. Original work published 1927).

Henderson, A. (2006). Perspectives and practice: the satisfaction construct.

Qualitative Research Journal, 6(1), 20-35.

http://www.health.qld.gov.au/hcc/docs/hcc_guidelines_web.pdf

http://www.health.qld.gov.au/hcq/publications/PtnCentreCare.pdf

http://www.aph.gov.au/Library/pubs/bd/2009-10/10bd132.pdf

http://www.nova.edu/ssss/QR/QR3-1/heath.html%20Retrieved%20October%2010

Reference List

206

Hsieh, S. Y., Thomas, D., & Rotem, A. (2005). The organisational response to

patient complaints: a case study in Taiwan. International Journal of

Health Care Quality Assurance, 18(4), 308-320.

Hudak, P. L., & Wright, J.G. (2000). The characteristics of patient satisfaction

measures. Spine, 25(24), 3167-77.

Jonas-Simpson, C., Mitchell, G.J., Fisher, A., Jones, G., & Linscot, J. (2006).

The experience of being listened to: A qualitative study of older adults in

long-term care settings. Journal of Gerontological Nursing, 32(1), 46-53.

Johnson, A., & Silburn, K. (2000). Community and consumer participation in

Australian health services—an overview of organisational commitment

and participation processes. Australian Health Review, 23(3), 113-121.

Johnson, M. E. (2000). Heidegger and meaning: implications for

phenomenological research. Nursing Philosophy, 1(2), 134-146

Jones, J., Wilson, B., Humphreys, J., & Griffin, L. (2003). Rural consumers’

complaints about health services. Retrieved from

http://www.abc.net.au/rural/ruralhealth2003/stories/s799425.htm

Jones, J. A., Humphreys, J. S., & Wilson, B. (2005). Do health and medical

workforce shortages explain the lower rate of rural consumers‘

complaints to Victoria‘s health services commissioner? Australian

Journal of Rural Health, 13(6), 353-358.

http://www.abc.net.au/rural/ruralhealth2003/stories/s799425.htm%20Retrieved%20March%2015

Reference List

207

Jones, J. A., Meehan-Andrews, T. A., Smith, K. B., Humphreys, J. S., Griffin,

L., & Wilson, B. (2006). There‘s no point complaining, nothing changes:

rural disaffection with complaints as an improvement method. Australian

Health Review, 30 (3): 322-332.

Kavaler, F., Spiegler, A.D. (2003). Risk management in health care institutions

a strategic approach. (2nd

Ed.) Canada: Jones and Bartlett Publishers.

Koch, T. (1995). Interpretive approaches in nursing research: the influence of

Husserl and Heidegger. Journal of Advanced Nursing, 21(5), 827-836.

Kumar, K., & Subramanian, R. (1998). Meeting the expectations of key

stakeholders: stakeholder management in the health care industry. SAM

Advanced Management Journal. 63(2), 31-41.

Larkin, M., Watts, S., & Clifton, E. (2006). Giving voice and making sense in

interpretative phenomenological analysis. Qualitative Research in

Psychology, 3(2), 102-120.

Laverty, S. M. (2003). Hermeneutic phenomenology and phenomenology: A

comparison of historical and methodological considerations.

International Journal of Qualitative Methods, 2(3). Article 3.

Lazarus, R. S. (1991). Emotion and adaptation. New York: Oxford University

Press.

Reference List

208

Lazarus, R. S. (1991a). Cognition and motivation in emotion. American

Psychologist, 46(4), 352-367.

Lazarus, R. S. (1993). From psychological stress to the emotions: A history of

changing outlooks. Annual Review of Psychology, 44, (1)

Lester, S. (1999) An introduction to phenomenological research. Retrieved

from: http://www.devmts.demon.co.uk/resmethy.htm

Liamputtong, P., & Ezzy, D. (2005). Qualitative research methods. Melbourne:

Oxford University Press.

Lim, C.I. (2009). Concept of the EMS. Retrieved from

http://www.centreforsmart.co.uk/smp/smas_briefing.php

Lindseth, A., & Norberg, A. (2004), A phenomenological hermeneutical method

for researching lived experience. Scandinavian Journal of Caring

Services, 18(2), 145-153.

Lundqvist, M. J., & Axelsson, A. (2007). Nurses perceptions of quality

assurance. Journal of Nursing Management, 15, 51-58.

MacDougall, C., & Fudge, E. (2001). Planning and recruiting the sample for

focus groups and in-depth interviews. Qualitative Health Research,

11(1), 117-126.

http://www.devmts.demon.co.uk/resmethy.htm

http://www.centreforsmart.co.uk/smp/smas_briefing.php

Reference List

209

Malthouse, E. C., Oakley, J. L., Calder, B. J., Iacobucci, D. (2003). Customer

satisfaction across organizational units. Retrieved from

http://www.mediamanagementcenter.org/research/customersatisfaction.p

df

Marcinowicz, l., Chlabicz, S., & Grebowski, R. (2009). Patient satisfaction with

healthcare provided by family doctors: primary dimensions and an

attempt at typology. BMC Health Services Research, 9, 63-68.

Marshall, M. N. (1996). Sampling for qualitative research. Family Practice,

13(6), 522-525.

McConnell-Henry, T., Chapman, Y., & Francis, K. (2009). Husserl and

Heidegger: Exploring the disparity. International Journal of Nursing

Practice, 15(1), 7-15.

McHugh Schuster, P., Nykolyn, L. (2010). Communication for nurses: how to

prevent harmful events and promote patient safety. Philadelphia: F.A.

Davis Company.

Milgate, S. (2003). Quality in Australian health care study Examined or

exposed? Retrieved from http://www.adf.com.au/archive.php?doc_id=98

Moore, P., & Wishart, J. (2003). Consumer experiences of health complaints in

South Australia. In ACT Community and Health Service Complaints

Commissioner, (Ed.), Proceedings of the 4th

National Health Care

http://www.mediamanagementcenter.org/research/customersatisfaction.pdf

http://www.mediamanagementcenter.org/research/customersatisfaction.pdf

http://www.ingentaconnect.com/content/bsc/ijn;jsessionid=210ftaeue269l.alice

http://www.ingentaconnect.com/content/bsc/ijn;jsessionid=210ftaeue269l.alice

http://www.adf.com.au/archive.php?doc_id=98

Reference List

210

Complaints Conference; March 27—28, Canberra: Complaints

Commissioner.

Morse, J. M., & Field, P. E. (1995). Qualitative research methods for health

professionals. (2nd

ed.) London: Sage Publications.

Mullan, F. (2001). A founder of quality assessment encounters a troubled system

firsthand. Health Affairs, 20(1), 137-141.

Newell, S. M., Jones, D. A., & Hatlie, M. J. (2010). Partnership with patients to

improve patient safety. Medical Journal of Australia, 192(2), 63-64.

Nisselle, P. (2004). Managing medical indemnity: must we choose between

quality assurance and risk management? Medical Journal of Australia,

181(2), 64-65.

Nyer, P. U. (2000). An investigation into whether complaining can cause

increased consumer satisfaction. Journal of Consumer Marketing, 17(1),

9-19.

O‘Leary, A. (2004). The essential guide to doing research. London: Sage

Publications.

Otani, K., Waterman, B., Faulkner, K. M., Boslough, S., Burroughs, T. E.

Dunagan, W.C. (2009). Patient satisfaction: Focusing on "excellent".

Journal of Healthcare Management, 54(2), 93-103.

Reference List

211

O‘Toole, G. (2008). Communication core interpersonal skills for health

professionals. Australia: Elsevier.

Peacock, E. J., & Wong, P. T. P. (1990). The stress appraisal measure (SAM): A

multidimensional approach to cognitive appraisal. Stress Medicine, 6(3),

227-236.

Phelps, E. A. (2006). Emotion and cognition: Insights from studies of the human

amygdala. Annual Review of Psychology, 57, 27–53

Ploeg, J. (1999). Identifying the best research design to fit the question. Part 2:

Qualitative designs. Evidence-Based Nursing, 2(2), 36-37.

Ploger, K. A. (1994). Hermeneutic phenomenology: A methodology for family

health and health promotion study in nursing. In P. Benner (Ed.),

Interpretive phenomenology: Embodiment, caring, and ethics in health

and illness. (pp. 71-72): Thousand Oaks, CA: Sage.

Podger, A., & Hagan, P. (1999) Reforming the Australian health care system:

the role of government. Department of Health and Aged Care occasional

papers. New Series, No. 1. Retrieved from

http://catalogue.nla.gov.au/Record/2936830

Polkinghorne, D. (1983). Methodology for the human sciences: systems of

inquiry. Albany: State University New York Press.

http://catalogue.nla.gov.au/Record/2936830

Reference List

212

Queensland Public Hospitals Commission of Inquiry Report (2005). Queensland

Government. Retrieved from http://www.qphci.qld.gov.au/

Queensland Health Statewide Patient Satisfaction Survey: State Report. (2006).

Retrieved from

http://www.health.qld.gov.au/quality/pat_sat_survey/patsat.asp

Redfern, S., J. & Norman, I., J. (1990). Measuring the quality of nursing care: a

consideration of different approaches. Journal of Advanced Nursing, 15

(11), 1260-1271.

Review of professional indemnity arrangements for health care professionals

(Australia).Compensation and professional indemnity in health care:

final report. (1995). Commonwealth of Australia.

Rodgers, A., Karlsen, S., & Addington-Hall, J. (2000). All the services were

excellent. It is when the human element comes in that things go wrong:

dissatisfaction with hospital care in the last year of life. Journal of

Advanced Nursing, 31(4); 768-774.

Romios, P., Newby, L., Wohlers, M., Spink, J., Gleeson, D., & Goldstein, D.

(2003).Turning wrongs into rights: learning from consumer reported

incidents: An annotated literature review. Department of Health and

Ageing, Commonwealth of Australia.

http://www.qphci.qld.gov.au/

http://www.health.qld.gov.au/quality/pat_sat_survey/patsat.asp

Reference List

213

Sandelowski, M. (1986). The problem of rigor in qualitative research. Advances

in Nursing Science, 8(3), 27-37.

Sandelowski, M. (1995). Sample size in qualitative research. Research in

Nursing & Health, 18(2), 179-183.

Schoefer, K., & Ennew, C. (2005). Emotions responses to service complaint

experiences: The role of perceived justice. Journal of Services

Marketing, 19(5), 261-270.

Schoefer, K., & Diamantopoulos, A. (2008). The role of emotions in translating

perceptions of (in) justice into post complaint behavioural responses.

Journal of Service Research, 11(1), 91-103.

Schwartz, L., & Overton, D. (1992).The management of patient complaints and

dissatisfaction. Emergency Medicine Clinics of North America, 10(3),

557-572.

Scobie, S., Thomson, R., McNeil, J. J., & Phillips, P. A. (2006). Measurement of

the safety and quality of health care. Medical Journal of Australia, 184

(10), S51-S55.

Simons, J. A., Irwin, D. B., & Drinnien, B.A. (1987). Psychology—the search

for understanding. Retrieved from

http://honolulu.hawaii.edu/intranet/committees/FacDevCom/guidebk/tea

chtip/maslow.htm

http://honolulu.hawaii.edu/intranet/committees/FacDevCom/guidebk/teachtip/maslow.htm

http://honolulu.hawaii.edu/intranet/committees/FacDevCom/guidebk/teachtip/maslow.htm

Reference List

214

Smith, J.A. (1995). Semi-structured interviewing and qualitative analysis. In:

J.A. Smith, R. Harre, & L.Van Langengrove (Eds), Rethinking methods

in Health Psychology (pp.9-26). London: Sage Publications.

Smith, K.B., Humphreys, J.S., & Jones, J.A. (2006). Essential tips for measuring

levels of consumer satisfaction with rural health service quality. The

International Electronic Journal of Rural and Remote Health Research,

Education Practice and Policy, 6(594). Retrieved from

http://rrh.deakin.edu.au

Smith, J.A., & Osborn, M. (2003). Interpretative phenomenological analysis. In

J.A. Smith (Ed), Qualitative Psychology: A Practical Guide to Methods

(pp. 53-80). London: Sage Publications.

Stauss, B. (2002). The dimensions of complaint satisfaction: process and

outcome complaint satisfaction versus cold fact and warm act complaint

satisfaction. Managing Service Quality, 12(3), 173-183.

Stephens, N., & Gwinner, K. P. (1998). Why don't some people complain? A

cognitive-emotive process model of consumer complaint behavior.

Journal of the Academy of Marketing Science, 26(3), 172-189.

Stein-Parbury, J. (2009). Patient and person, interpersonal skills in nursing. (4th

Ed.). Australia: Elsevier.

http://rrh.deakin.edu.au/

Reference List

215

Stiller, K., Cains, G., & Drury, C. (2009). Evaluating inpatient satisfaction with

a physiotherapy service: A rehabilitation centre survey. International

Journal of Therapy and Rehabilitation, 16(7), 376-382.

Tamparo. C. C., & Lindh, W. Q. (2008). Therapeutic communication for health

care. (3rd

Ed.). Delmar Cengage Learning.

Taskforce on Quality in Australian Health Care: Final Report to the Hon Dr

Michael Wooldridge MP, Minister for Health and Family Services.

(1996) Commonwealth of Australia.

Taylor, D., Kennedy, M. P., Virtue, E., & McDonald, G. (2006). A multifaceted

intervention improves patient satisfaction and perceptions of emergency

department care. International Journal for Quality in Health Care, 18(3),

238-245.

Taylor, D. M., Wolfe, R., & Cameron, P. A. (2002). Complaints from

emergency department patients largely result from treatment and

communication problems. Emergency Medicine Australasia, 14(1), 43-

49.

Taylor, D. M., Wolfe, R. S., & Cameron, P. A. (2004). Analysis of complaints

lodged by patients attending Victorian hospitals, 1997–2001. The

Medical Journal of Australia. 181(1), 31-35.

Reference List

216

Tito, F., & Roche, S. (1999). Partnerships in general practice: A discussion

paper prepared for Consumers‘ Health Forum of Australia. ACT: The

Forum.

Turner, P. K., & Krizek, R. L. (2006). A meaning-centered approach to customer

satisfaction. Management Communication Quarterly, 20(2), 115-147.

Van Der Weyden, M. B. (1995). Politics and publishing: the quality in

Australian health care study. Medical Journal of Australia, 163, 453-454.

Van Der Weyden, M. B. (2005). The Bundaberg hospital scandal: the need for

reform in Queensland and beyond. Medical Journal of Australia, 183(6),

284-285.

Van Manen, M. (1997). Researching lived experience: human science for an

action sensitive pedagogy. (2nd

ed.). Ontario: The Althouse Press.

Van Manen, M. (2002). Phenomenological Inquiry. Retrieved from


Van Manen, M. (2007). Phenomenology of practice. Phenomenology and

Practice, 1, 11-30.

Varney, H., Conneely, M., & Phillips, S. (2005). Using consumer groups in an

audit of complaints. Health Issues, 84, 30-33.


Reference List

217

Vikas, M., & Kamakura,W. A. (2001). Satisfaction, repurchase intent, and

repurchase behavior: Investigating the moderating effect of customer

characteristics. Journal of Marketing Research, 38 (1), 131-142.

Vinagre, M. H., & Neves, J. (2008). The influence of service quality and

patients‘ emotions on satisfaction. International Journal of Health Care

Quality Assurance, 21(1), 87-103.

Vincent, C. A., & Coulter, A. (2002). Patient safety: what about the patient?

Quality and Safety in Health Care, 11(1), 76-80.

Wal, G. V., & Lens, P. (1995). Handling complaints in hospitals. Health Policy,

31(1), 17-27.

Warren, C., & Karner, T. 2005. Discovering qualitative methods: Field

research, interviews, and analysis. Los Angeles: Roxbury Press.

Watson, L., & Spence, M. T. (2007). Causes and consequences of emotions on

consumer behaviour: A review and integrative cognitive appraisal theory.

European Journal of Marketing, 41(5/6), 487-511.

Wessel, M., Helgesson., & Lynöe. N. (2009). Experiencing bad treatment:

Qualitative study of patient‘s complaints concerning their treatment by

public health-care practitioners in the country of Stockholm. Clinical

Ethics 4(4), 195-201.

Reference List

218

Wheatley, M.J., (1998). Bringing life to Organizational change. Retrieved from:

http://www.margaretwheatley.com/articles.html

Wiele, T. v. d., Boselie, P., & Hesselink, M. (2002). Empirical evidence for the

relationship between customer satisfaction and business performance.

Managing Service Quality, 12(3), 184-193.

Wilson, L., & Fulton, M. (2000). Risk management: how doctors, hospitals and

MDOs can limit the costs of malpractice litigation. Medical Journal of

Australia, 172(8), 77-80.

Wilson, R. M., Runciman, W. B., Gibberd, R. W., Harrison, B. T., Newby, L., &

Hamilton, J. D. (1995). The quality in Australian health care study.

Medical Journal of Australia, 163(9), 458-471.

Wilson, R. M., Harrison, B. T., Gibberd, R. W., & Hamilton, J. D. (1999). An

analysis of the causes of adverse events from the quality in Australian

health care study. Medical Journal of Australia, 170, 411-415.

Wilson, R. M., & Van Der Weyden, M. B. (2005). The safety of Australian

healthcare: 10 years after QAHCS. Medical Journal of Australia, 182(6),

260-261.

Wojnar, D. M., & Swanson, K. M. (2007). Phenomenology: an exploration.

Journal of Holistic Nursing, 25(3), 172-180.

http://www.margaretwheatley.com/articles.html

Reference List

219

Zairi, M. (2000). Managing customer dissatisfaction through effective

complaints management systems. The TQM Magazine, 12(5), 331-335.

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



against me


being disrespected


against me


against me


being disrespected


against me



against me



irrevocable loss


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


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


against me

ANXIETY- facing uncertain


being disrespected


against me



being disrespected

DISGUST- taking in or being too close

to an indigestible object or (metaphorically speaking) idea


against me



being disrespected


how to make a complaint is not

evident



(LANGUAGE)

Having some control back

(LANGUAGE) constant expressions of being disrespected evident

Feeling out of control-not something he was

used to

Appendices

231


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


RELIEF- a distressing goal-

incongruent condition that has

changed for the better or gone away



against me


against me



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


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


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


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


Appendix O)

Appendices

233


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


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


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


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


Appendix P)

Appendices

234


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


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



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

Appendices

244

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?...

Appendices

245

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

Appendices

246

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

Appendices

247

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

Appendices

248

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...

Appendices

249

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

Appendices

250

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

Appendices

251

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

Appendices

252

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...

Appendices

253

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...

Appendices

254

... 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.

Appendices

255

Appendix R: Poster—London, UK.

Appendices

256

Appendix S: Oral Presentation—Miami, USA

Appendices

257

Appendix T: Oral Presentation—Molde, Norway

Appendices

258

Appendix U: Oral Presentation—Adelaide, South Australia

Appendices

259

Appendix V: Oral Presentation—Surfers Paradise, QLD

Appendices

260

Appendix W: Confirmation Seminar Notification

Appendices

261

Appendix X: Final Seminar Notification

Appendices

262

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.

263

INTENTIONALLY LEFT BLANK

Documents

Chapter 1: Overview of the Study · Phenomenological Analysis (IPA) approach, guided by the philosophical influences of Heidegger (1889-1976). As part of the interpretive endeavour