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Enfermería Global

On-line version ISSN 1695-6141

Enferm. glob. vol.13 n.36 Murcia Oct. 2014




Quality of service: user satisfaction from a nursing perspective

Calidad de servicio: satisfacción usuaria desde la perspectiva de enfermería



Gallardo Ferrada, Amanda* and Reynaldos Grandón, Katiuska**

*Nurse. Mention Masters in Nursing Management. Faculty of Medicine, Pontificia Universidad Católica de Chile. E-mail:
**Nurse Midwife. Commercial Engineer. MBA. Phd Business Studies. Faculty of Nursing, University Andrés Bello. Chile.




One of the important aspects that in many cases determine the competitiveness and permanence in the market of institutions is the quality of service. In addition, there is a need to understand how the user perceives and forms expectations. Among those that aspire to identify what it is that influences the quality of care are health institutions.
Objective: Analyze studies performed in the health field with a focus on the perception and expectation of service.
Design and method: Investigation of the following databases was performed for this review: PubMed, Trip Database, Cochrane, as well as Google Scholar and SciELO, in order to analyze studies related to the quality of service. The limits included: free access of complete texts, in Spanish and/or English, from the last 10 years. Seventeen articles were selected for review.
Results: All articles include the evaluation of perception and the quality of service. Fifteen of those articles refer to health services.
Conclusions: The quality of service is perceived in different ways. There are multiple factors that determine the perception of the quality of service, one of which is the user's state of health. Keywords: Administration, user satisfaction, quality of service.

Key words: Administration; user satisfaction; service quality.


Uno de los aspectos relevantes y que en muchos casos determina la competitividad y permanencia en el mercado de las instituciones es la calidad de servicio. Frente a esto surge la necesidad de conocer cómo el usuario percibe y forma expectativas. Dentro de las empresas que aspiran a la calidad en su atención se encuentran las instituciones de salud siendo relevante identificar aspectos que influyen en la calidad de servicio.
Objetivo: Analizar los estudios realizados en el área de salud con enfoque en percepción y expectativas de servicio.
Diseño y método: Para esta revisión se realizó una búsqueda a través de las bases de datos: PubMed, Trip Database, Cochrane, además de Google Scholar y SciELO, con el propósito de analizar estudios relacionados con calidad de servicio. Los límites comprendieron: textos completos, idioma español y/o inglés, de los últimos 10 años y acceso gratuito. Se seleccionaron 17 artículos para la revisión.
Resultados: Todos los artículos comprenden la evaluación de la percepción y la calidad de servicio. De ellos 15 hacen referencia a servicios de salud.
Conclusiones: La calidad de servicio es percibida de diferentes maneras. Existen múltiples factores que determinan la percepción de calidad de servicio uno de ellos es el estado de salud de los usuarios.

Palabras clave: Administración; satisfacción usuaria; calidad de servicio.



According to The Dictionary of the Royal Spanish Language, the quality of service is defined as "Property or set of properties inherent to something, which permits judgment of its value" Montgomery defines it as "The degree to which products meet the demands of the people who use them"(2). Health services as in every business, must face diverse challenges, pressures, and threats in order to maintain and develop the quality of services provided, they must know how to adjust and adapt key business principles (tasks, technologies, organizational structures, people, and the external environment) in different situations such as: the emergence of new technologies, globalization, political changes, and the changes in knowledge(3,4).

Quality Service and User Satisfaction

These factors explain the competitive environment in which companies are immersed, and incidentally our health organizations which fight for proper coordination of processes as well as the creation of conditions that generate a difference between the rest of competitors in the health field and that in turn grant value to the given service(5). There are nursing organizations in search of distinctive characteristics that establish topics related to quality of care and client satisfaction in the market as a priority of investigation, for example: the American Association of Critical-care Nurses (AACN) published this topic as top priority: "effective and appropriate use of technology in order to obtain analysis, treatment, and optimal patient results"(6). The American Organization of Nurse Executives (AONE) established as a research priority for the year 2000: 1) studies about personnel, 2) advocacy for patient care and 3) technology(7). The Agency for Healthcare Research and Quality (AHRQ) is an agency that finances the investigation of health care and that aims to improve quality, adequacy and effectiveness of health services, as well as promotes improvement in clinical practice, organization, funding and the provision of health services(8).

A change in the nature and distribution of the market has also affected a change in clients. The modern client is more informed, selective, has an improved ability to discern, is more segmented, has a higher standard of living, etc. For this reason, it is required to monitor the level of client satisfaction with respect to services and products, thus, the challenge of the institution is to constantly innovate the quality of personnel and customer orientation. To achieve this, focus must be placed on the customer in order to begin to identify which factors affect user satisfaction(9). On many occasions these factors are not evident in a conscious manner, however, they can be detected and collected in order to deliver services that aspire to satisfy customer needs.

Evaluation of the Quality of Service

There are several ways to evaluate the quality of service, considering that this is a relatively contemporary practice in our country. In 1985 Parasuraman, Berry and Zeithaml, developed a tool denominated SERVQUAL (Service Quality) in order to measure the quality of service, focusing on the measurement of the gap between user perceptions and expectations with respect to the granted service. When we speak of perception we are referring to the level in which the client believes the institution to complete the provided services. Expectations are defined as the desired services that are to be given by the organization(10). These factors that influence user satisfaction are increasingly studied in our country. There are some findings performed in health organizations in which client perspectives are evaluated in order to acquire information to enhance attention and processes. These investigations are primarily performed in hospitals.

User Satisfaction in Chile

This issue is relevant in our country, the Ministerio de Salud (MINSAL) stated in its Mission where to look for "...timely accommodation of the needs of individuals, families and communities, with the obligation to render accounts to the citizen and promote the participation there of in the exertion of their rights and duties" The MINSAL is responsible for formulating and determining health policy. Consequently, it has among other things, the development of health objectives for the decade. Within the health objectives we emphasize the number IV which consists of "To provide services in accordance with the expectations of the population", considering objectives such as meeting the legitimate expectations of the population, as well as seeking to increase the level of satisfaction of the population with its health system(12). From this perspective and according to the results obtained, the new objectives for user satisfaction should aim to redefine the relationship between people and the sector, promote the full realization of the rights and responsibilities of people in health and relieve the significant aspects of user satisfaction. In addition, the challenge will incorporate the aspects of user satisfaction with formal training of medical and technical professionals, as well as paramedics, as the user orientation is a concern that must be incorporated in advance between those that will form health care teams(13). In reference to the aforementioned topic and for the reason that this is a developing issue in this country, especially in the health field, there exists a need for analysis of these aspects. The present article states: perception and user satisfaction, quality of health service and finally, the discussion and conclusion of the declared topic.



An integrative interview was performed, allowing the simultaneous inclusion of quantitative (experimental and non-experimental) and qualitative research to better understand the phenomenon of interest. For this review a database search was performed: PubMed, Tripdatabase, Cochrane, as well as Google Scholar y SciELO, for the purpose of analyzing studies in relation to the quality of service, user perception and expectations that determine their satisfaction with the given services, in order to have a general vision of how the customer perceives and generates expectations of a particular service. The following key words in Spanish and English were used respectively: perception, administration, user satisfaction, quality of service. Complete texts that were available in Spanish and/or English were considered. Works exceeding 10 years of existence were excluded as well as those that only had an abstract available and could not be considered a complete text at the moment the databases were investigated. For article selection, the opinions of experts in the selected fields were considered in order to direct and narrow the search on the topic, as well as the limits of the investigation. Finally, 17 research articles in which 11 used quantitative methodology, 3 qualitative methodology, 1 used mixed method (qualitative and quantitative) and 2 corresponded to literature reviews were analyzed. Of all the articles, 10 are texts in Spanish and 7 are in English. For this reason, the following question ensues, How does perception and expectation influence user satisfaction in relation to the given health services?



Quality of Service

The technical requirement stipulates that the provider has the knowledge and skills in order to perform the appropriate clinical procedures as needed by the client, the interpersonal requirement refers to the interaction between the provider and client in the activity of attention, respect and mutual cordiality, and finally, the infrastructure requirement refers to characteristics of the site such as the cleanliness, illumination, and ventilation of the environment(14).

Velandia et al.(15) indicates that punctuality and the quality of care services were well evaluated by the Colombian population. Likewise, some factors that determine variations in assessments of punctuality and quality were identified, including reasons for not using health care services. In relation the reasons for not using the services, it was found that 64.7% of the population that did not use heath care services, cited "reasons" associated with problems in quality. Accessibility was found to be among the most important factors, such as: long distance, lack of money and the credibility of health agents. A set of factors or variables associated with the variations in opportunity such as variations in quality (satisfaction), between those that include affiliation with social security was identified. Other factors, such as the health plan used in order to access medical attention, were associated solely with opportunity. That which has to do with the entity of affiliation, was associated exclusively with quality or satisfaction. However, the quality of service in general was well evaluated. In addition, the time of attention, treatment from personnel, management capabilities and coordination between information services, as well as complaints and management of user data were influential aspects in the overall perceived quality by the client(16). Another aspect to consider in the evaluation of the quality of service is the perceived health status of the client. Users with a poor mental health status have less positive judgments of aspects that are related to the accessibility of services and interpersonal aspects of care. A poor physical health status however forecasts judgments less positive of aspects such as the cleanliness of the building and confidentiality of consultation with a family physician, among others, making all of these aspects statistically significant(17). A systematic revision on the subject performed by Patterson, et al.(18) in the United Kingdom, established that in health literature the participation of employees in groups of continuous quality improvement, obtain better health results for their users. From another perspective, a study performed in the USA established that hospitals that have a greater number of nurses can be associated with a better experience for patients(19).

In relation to the contribution of nursing to the quality of service, the data alone does not provide the entire image. It is necessary to evaluate the workplace, teamwork, systems and leadership. Additionally, the incentives for change in behavior both individually and systematically are relevant in order to have an eventual influence in the quality of user care. Quality nursing care should focus on: the person, identifying their values, needs and expectations with respect to their own health and social assistance; communicate and facilitate the pertinent information that allows shared decision making, informed selection, and allow participation in the evaluation of care. On the other hand, care must be effective, that is, safe and evidence-based in relation to the provided treatment and the context in which care is carried out and finally, must consider the systems of care with regard to the context in which it (for example, security systems, human resources, continuity of care) is provided. This includes structures, processes and behavior patterns that allow nurses to focus on the person. Finally, the care provided should be safe and effective(20).

Fitzpatrick cited in Caminal(21) states that "There are three reasons for why satisfaction should be considered an important measure of the care process. First, there are studies that show satisfaction is a good predictor of the fulfillment of treatment by patients and of the adherence to the consultation and provision of service. Secondly, satisfaction is a useful instrument for assessing consultations and modes of communication. For example, the success in informing or involving patients in making decisions about the type of care. Thirdly, the patient's opinion can be systematically used to improve the organization of the services provided." The population must be part of the improvement of the quality of service given, since they provide essential information for the functioning of the institutions from the perspective of the client and constitute an element of improvement of the quality of care.

Perception and User Satisfaction

Llanos et al. compares the scales of Likert and Vigesimal to assess the satisfaction of patients treated in a hospital. The obtained results in the satisfaction of patients cared for in a hospital differ according to the scale used for measurement. The chosen scale must consider the objectives of investigation so that its importance lies in achieving proper measurement of the quality of service that permits decision-making, with the purpose of improving this quality.

Salvador(23) found that the client positively perceives the existence of structural characteristics such as efficiency and tangibility. The client, however, values treatment and professional competency more. There are certain perceived aspects such as: long waiting times, lack of affection in treatment and deficiencies in comfort, that influence the level of user satisfaction(24). Riveros, et al. refers to how the interactive nature of health services and their simultaneous production and consumption elevates the need to examine the perceptions of those implicated in the finding, both professionals and users, showing that in relation to the variable professional and ethical commitment, were perceived more negatively by the clients. In relation to the variable of concern of the hospital, and the commitment of personnel to provide quality care, the most positive perception was of the users. The most demanding opinions of personnel are self-critical to their responsibilities and can promote the acceptance of an effective application of advanced marketing in the establishment. The personnel were more demanding than the users following a tendency of self-criticism.

A study of Native Americans over the age of 50 regarding their perceptions of health service providers showed a significant discord between the new form of interaction between patients and health care providers. The discord reflects a trend that providers were more critical of their own behavior than the patients. These findings suggest that service providers often create greater satisfaction than they thought(26).

From the client's perspective Anden et al.(27) showed that the result of going to a medical consultant is the cure or relief of symptoms, compression, confirmation, tranquility, and change in self-perception and satisfaction of their needs. Camgõz-Akdag & Zineldin(28) argue that client satisfaction is a cumulative satisfaction that comprises five factors "5Qs model" that encompasses technical and functional qualities, interaction, infrastructure and environment, and services. Of these, the three factors of major concern for people that receive treatment in hospitals in Turkey are: the quality of infrastructure, environment and atmosphere and technical quality. In addition, there are similar deficiencies identified by hospitalized patients in Turkey, Jordan and Egypt which were the skills and amiability of doctors, the courtesy of nurses and responsiveness to their needs.

Riveros & Berné reports that user satisfaction is more easily achieved if an organizational culture is oriented toward the client and implements appropriate policies and quality of service using both the traditional marketing and new approaches of market orientation or to the user and marketing relations. The consideration of these new marketing approaches as important factors in order to achieve satisfaction of user needs incorporates the need of a greater and mutual exchange between officials and users into public domain, that would help to change greater product orientation, which we initially mentioned, by a more oriented client or user. These aspects of market application should effectively integrate management processes of these hospitals(29). Riveros et al.(30) studied the relationship between user orientation and the satisfaction of service, in order to focus on confirming those factors or principal components that have a greater impact on the level of user satisfaction and hospital patients both in the aspect of user orientation and different elements of the service. This will build a foundation for the implementation of improvements for the aforementioned health centers and in consequence, greater client satisfaction.



The revised topics provide relevant information about how users perceive health and what aspects become more relevant in certain situations. Users declare high levels of satisfaction, however, complaints and dissatisfaction are also present.

It was important to exhibit that the results in satisfaction vary according to the instrument of collection of data selected in order to carry out the study, hence, the importance of expertise and training of the people who engage in this area with the purpose of correctly aligning the methodology with the objectives being pursued to perform operationally effective and efficient research.

It is also noted that the opinions of satisfaction with respect to the quality of care will have greater validity if one takes into consideration the state of health of the client that is to be evaluated in parallel.

The value of the quality of service influence tangible factors, however, the treatment, professional skills and orientation of the organization towards the user are factors that are constantly repeated within the results of the investigation, making this aspect crucial at the time care is provided. The 5Qs model suggests there should be harmonization between different dimensions (technical, functional qualities, interactions, infrastructure, the environment and air quality and technical quality) in order to achieve greater user satisfaction with a consequent improvement in the quality of care.

Based on the purpose of this review, having an understanding of user perception and what prompts their level of satisfaction can contribute to the redesign of quality management processes and future orientation of their strategies. This reaffirms that hospitals can and should offer both quality of clinical care and provide a pleasant user experience.

From this perspective, the participation of health service employees in groups of continuous improvement becomes a strategy that will ultimately improve results with respect to the quality of care provided to clients. However, this is a social phenomenon that points to multiple causes. There are reasons for not using health services that relate to: forecasting, geographical problems that limit access and lack of money in families. In order to influence these aspects, political and economic approaches that focus on social health determinants are required.



The identification of expectations and perceptions of users based on the quality of service is essential in health systems, MINSAL presented this problem as a challenge highlighting the need for the incorporation of these topics into the training of health professionals. As described in the results, studies reveal that a greater number of nurses can be associated with a better experience from the perspective of the users. With this, it is confirmed that the ontological dimension of our discipline is care, which must be focused on the patient, with a biopsychosocial approach in context according to its values and identifying their needs and considering user expectations. All with the objective of providing quality care. It is essential in today's integrated management of health services, to meet clients through qualitative and quantitative information. The measure of these aspects becomes crucial if we have a population of participants that believes regarding the services granted, we will have a constant feedback from those perfectible points in practice, improving processes and helping he or she who works in a team become oriented to the user as a tool to improve quality.



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