International Journal for Quality in Health Care, 2019, 31(7), 556–562

doi: 10.1093/intqhc/mzy215
Advance Access Publication Date: 20 October 2018
Article

Article

The nature of patient complaints: a resource for

healthcare improvements
ANNA RÅBERUS1, INGER K. HOLMSTRÖM2,3, KATHLEEN GALVIN4,

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and ANNELIE J. SUNDLER1
1
Faculty of Caring Science, Work Life and Social Welfare, University of Borås, 501 90 Borås, Sweden, 2School of
Health, Care and Social Welfare, Mälardalens University, Västerås, Sweden, 3Department of Public Health and
Caring Sciences, Uppsala University, Sweden, and 4School of Health Sciences, University of Brighton, UK
Address reprint requests to: Anna Råberus, Faculty of Caring Science, Work Life and Social Welfare, University of
Borås, Sweden, 501 90 Borås, Sweden. Tel: +46 760 067666; Fax: +46 33 435 40 03; E-mail: [email protected]
Editorial Decision 27 August 2018; Accepted 10 October 2018

Abstract
Objective: The aim of this study was to explore the nature, potential usefulness and meaning of
complaints lodged by patients and their relatives.
Design: A retrospective, descriptive design was used.
Setting: The study was based on a sample of formal patient complaints made through a patient
complaint reporting system for publicly funded healthcare services in Sweden.
Participants: A systematic random sample of 170 patient complaints was yielded from a total of
5689 patient complaints made in a Swedish county in 2015.
Main outcome measure: Themes emerging from patient complaints analysed using a qualitative
thematic method.
Results: The patient complaints reported patients’ or their relatives’ experiences of disadvantages and
problems faced when seeking healthcare services. The meanings of the complaints reflected six themes
regarding access to healthcare services, continuity and follow-up, incidents and patient harm, commu-
nication, attitudes and approaches, and healthcare options pursued against the patient’s wishes.
Conclusions: The patient complaints analysed in this study clearly indicate a number of specific
areas that commonly give rise to dissatisfaction; however, the key findings point to the signifi-
cance of patients’ exposure and vulnerability. The findings suggest that communication needs to
be improved overall and that patient vulnerability could be successfully reduced with a strong
interpersonal focus. Prerequisites for meeting patients’ needs include accounting for patients’ pre-
ferences and views both at the individual and organizational levels.

Key words: patient complaints, healthcare, dissatisfaction, qualitative approach, experiences

Introduction patients. Understanding the issues and details of patient complaints may
Complaints registered by patients are considered important for indicat- provide directions for healthcare improvements.
ing problems and obtaining feedback on healthcare services [1]. Despite
the great importance of the quality of care and patient safety, some
patients suffer harm from medical care [2, 3]. In previous research,
Background
patient safety-reporting systems were used to study healthcare quality [3, The debate on patient safety and the quality of healthcare services
4]. However, few studies have focused on problems reported directly by has mainly represented a narrow clinical perspective, neglecting the

© The Author(s) 2018. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved.
For permissions, please e-mail: [email protected] 556
The nature of patient complaints • Patient satisfaction 557

patients’ perspective. Establishing a broader framework for addres- explore the nature, potential use and meaning of complaints lodged
sing patient safety will rely on understanding patients’ experiences by patients and their relatives.
[5–7]. Quality and improvement needs have also been reported to
motivate patients’ complaints. Patients often draw attention to pre-
vious mistakes and preventing such mistakes or incidents from being
Method
repeated [8, 9]. In European countries and the USA, for example, Research design
evidence suggests that patients’ complaints provide valuable infor- A retrospective study with a descriptive design was conducted to
mation about the source of medical errors, which is crucial for explore patient complaints made to a patients’ advisory committee
improving patient safety [7, 8, 10]. (PAC) in Sweden. The data were analysed using qualitative thematic
Patient complaints about healthcare services have reportedly analysis [20].
increased [11]. Such complaints are a growing concern for health-
care organizations worldwide and are a key mechanism for identify-
Setting
ing problems experienced by patients [12]. Patients’ main concerns
A systematic random sample of patient complaints filed with a PAC
are the quality and safety of healthcare services [13]. Other areas
in a Swedish county in 2015 was chosen. The primary task of PACs

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commonly reported are medical care and long waits [10, 14].
is to assist with problems arising from healthcare services. In
Further, communication and attitude problems, including unprofes-
Sweden, patients have the right to make complaints regarding
sional attitudes, have been associated with the quality of care and
healthcare services, and PACs for each county and municipality
patient safety [14]. Experiences of insufficient or inadequate infor-
receive such complaints. PACs are legislative, and they are an inde-
mation, in addition to unsatisfactory communication or failings in
pendent and impartial body without any authority to make judge-
respect and empathic staff responses are common [15, 16]. Patient
ments or punishments regarding healthcare. They review reports
complaints may also underline the hospital management’s handling
about concerns regarding publicly financed healthcare services.
of complaints and the outcomes offered [11].
These reports are documented in the reporting system by an admin-
Patient complaints can assist in identifying problems and risks
istrator, and in some cases the reports are supplemented with a writ-
related to healthcare services. A greater commitment to addressing
ten mail about a patient’s or a relative’s concern.
complaints can give insights into aspects of healthcare that trad-
itional quality and safety reporting systems fail to capture [4]. One
advantage of dealing with patient complaints is facilitating health- Sample and data collection
care providers’ preparedness to effectively manage and improve After obtaining permissions and approvals for the research, data
patient care [4, 17]. Patient risk and safety might be discussed in were collected in 2016 and shared from the patient complaint
relation to medical errors or failures. Reason [18] divided failures reporting system. A systematic random sample of 170 complaints
into two types: active failure, such as unsafe actions taken by clini- was derived from a total sample of 5 689 patient complaints regis-
cians caring for patients (i.e. individuals), and latent failure, such as tered in 2015 (see Fig. 1 for a flow chart, inclusion criteria and sam-
inevitable ‘resistant pathogens’ or factors arising from a stressful ple selection). The patient complaints analysed in this study
work environment, understaffing and inexperience (i.e. the organiza- contained detailed narratives written by a patient or a relative. Most
tion). Active failure often occurs due to insufficiency in latent condi- of the complaints were approximately one A4 page but ranged from
tions in the healthcare organization [18, 19]. three lines to six pages in length.
Although some key service delivery areas have been prevalent in
previous research on patient complaints, there remains a pressing
Data analysis
need to obtain in-depth knowledge of the impact and issues of
A qualitative thematic analysis was performed [20]. The objective
patient-reported problems. Therefore, the aim of this study was to
was to identify and describe patterns of meanings within the content
of the complaints. The first step of the analysis was to carefully read
the complaints repeatedly to get an overall sense of what was pre-
Total amount of patient complaints in year 2015 to the PAC in
VästraGötaland dominant in, and characteristic of, the data. Then the reading
became more systematically with attention on identifying meanings
5689 patient complaints in the data and understanding patterns in the text. Meaning units
were marked (the data were divided into fractions based on different
meanings) and patterns of meanings were identified, condensed and
arranged in initial themes. The authors attempted to delve deeper
Total number of patient complaints with a narrative from a patient into the data, reflecting on the complaint details, to allow new
or a relative recieved via mail or e-mail
insights to emerge. From this process, themes and subthemes were
elaborated through a reflective process. The emerging themes were
938 patient complaints
reviewed and further refined and discussed among the researchers.
The analysis involved an iterative movement between the whole
data and the emerging themes, going back and forth between ori-
Systematic random sample of patient complaints received ginal data and reflection. Finally, the analysis yielded 6 themes and
on the 5th, 10th, 15th, 20th and 25th of every month 14 subthemes that were used to organize and describe the findings.

170 patient complaints

Ethical considerations
This study was approved by the regional ethics committee in
Figure 1 Flow chart and sample selection of patient complaints. Gothenburg (DNo. 951-15). The data were provided anonymously
558 Råberus et al.

Table 1 Themes and related subthemes describing the content of the patient complaint

Themes Access to healthcare Continuity and Incidents and patient Communication Attitudes and Healthcare options
services follow-up harm approaches pursued against the
patient’s wishes

Subthemes Not getting in contact Concerns regarding Severe diagnoses Lacking information Being ignored Healthcare without
with healthcare deficiencies in being missed or on healthcare Being treated respect for the
services continuity misjudged Insufficient with patient’s views
Not getting access to Problems with follow- Patient harm from coordination disrespect Being overlooked by
healthcare, up visits or check- mistakes and healthcare
personal struggle ups incidents professionals
and a need ‘to fight’
Feelings of
abandonment when
delivery of

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healthcare services
ceases

by the patient complaints reporting system; none of the names or lacking access to care, treatment or aids’ included experiences of cer-
other personal information of patients, relatives, nurses or other per- tain healthcare services was ceasing. For example, patients described
sons in the complaints were obtained. the impact of physiotherapy being withdrawn.

Results Continuity and follow-up

Problems regarding continuity of healthcare and follow-up were
The patient complaints described experiences of patients’ and/or
described. Complaints included concerns regarding ‘deficiencies in
relatives’ dissatisfaction with healthcare services. These reports com-
continuity or problems with follow-up visits or check-ups.’
monly described experiences of significant incidents, disadvantages
Patients and/or relatives complained about lacking continuity in
and problems with an impact on the patient’s health, medical or
contact with physicians. Repeatedly consulting a new physician was
nursing care, or patient safety. There were experiences of problems
a concern, as it negatively influenced patient’s healthcare and
with access to healthcare services, problems regarding the quality of
treatment.
healthcare, and communication. Overall, the complaints can be
Another subject of the complaints was ‘problems with follow-up
viewed from two perspectives: individual failings among healthcare
visits or check-ups.’ The complaints described shortcomings of rou-
professionals in terms of fulfilling their responsibilities or deficiencies
tines and patients not being called for check-ups or examinations or
in their delivery of healthcare services, and problems at the organ-
delays in healthcare services.
izational level, comprising problems in, or resulting from, structural
conditions. The meanings of the complaints are further described in
six themes, with related subthemes, displayed in Table 1. The sub- Incidents and patient harm
themes are illustrated with examples and extracts from the patient The complaints also reported experiences of incidents and patient
complaints, shown in Table 2. harm. Some patients described ‘severe diagnoses being missed or
misjudged and patient harm arising from mistakes and incidents.’
‘Overlooking or misjudging severe diagnoses’ was reported, for
Access to healthcare services instance, by patients being treated by a GP, who were later found to
The complaints described problems regarding access and availability have advanced cancer. Such complaints of misjudgements and mis-
of different healthcare services. These complaints were characterized diagnoses involved life-threatening illnesses turning out to be some-
as ‘not getting in contact with healthcare services, not getting access thing else or serious conditions being missed.
to healthcare and needing “to fight” and feelings of abandonment ‘Patient harm from mistakes and incidents’ included, for
when access to healthcare, treatment or aids was lacking.’ example, post-operative wound infections and neurological injuries
‘Problems getting in contact with healthcare services’ concerned with ongoing symptoms several years after surgical procedures.
experiences of not being able to get in touch with healthcare services Other incidents involved treatment and care inflicting harm on
by telephone or online. This was troublesome when one could not inpatients.
contact the appropriate provider or department, as direct contact
was a prerequisite for access to healthcare. Other problems were
long wait times or missing information regarding whom to contact, Communication
and problems owing to the complexity of the telephone system. Communication problems were commonly described and seem to be
‘Not getting access to healthcare, personal struggle and a need a major characteristic of the analysed complaints. Patients were
“to fight”’ were exhibited in reports describing experiences of need- ‘lacking information about healthcare,’ or situations arose that were
ing to fight for help or having to overcome significant difficulties to a problem, often relating to ‘insufficient coordination.’
obtain healthcare. Reasons such as deficiencies in resources, staffing The complaints concerned situations where patients or relatives
and the number of occupied hospital beds were described. For ‘lacked information on healthcare.’ There were reports of communi-
instance, when patients had to leave the hospital without undergo- cation problems concerning information and advice. In numerous
ing their operation as scheduled. ‘Feelings of abandonment when situations, information regarding health, diseases, examinations or
The nature of patient complaints • Patient satisfaction 559

Table 2 Subthemes illustrated with extracts from patient complaints

Subtheme Extracts from patients complaints

Not getting in contact with healthcare services A patient not obtaining an appointment with the GP reported not having the medication needed:
‘It’s not the first time this has happened. Except that I must have my medication; it makes me feel
anxious.’ (82)
Another patient described being anxious when in pain and not being able to speak to any nurses
over the phone:
‘It almost took an hour; I was in pain and was really anxious before I got to talk to a nurse.’
(152)
Not getting access to healthcare services, personal A patient with hearing and vision impairments reported not having an interpreter needed for
struggle and a need ‘to fight’ communicating with healthcare services. Owing to this lack of support, the patient felt that they
had been discriminated against and could not handle daily life:
‘I feel I am discriminated against; I can’t handle my daily life.’ (9)
Feelings of abandonment when healthcare services A patient with a physical disability described previously accessed services for training as vital for

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cease sustaining physical functions. The patient reported feeling abandoned and their health being
threatened when they could no longer avail of those healthcare services:
‘Do they want us to be worse? // Why destroy our lives?’ (149)
Deficiencies in continuity A patient reported a lack of continuity in contact with physicians. Repeatedly getting a new
physician cause the patient to feel vulnerable and frustrated. The patient was concerned because
this negatively influenced the care and treatment:
‘During the time that I have been a patient at this clinic [two years], there has been no continuity
at all of doctors. My sick leave has lapsed every time before I could get a new appointment
with the GP. I have contacted them several times, and I constantly hear, ‘We do not have staff’.
Every time, except once, I have been consulted by new doctors.’ (150)
Problems with follow-up visits or check-ups A patient with a long-term illness, who required regular check-ups to test blood samples,
described being overlooked when there were changes in the staffing at the local healthcare
centre:
‘I was overlooked, should have been checked up regularly for my blood samples. That is no
patient safety at all.’ (90)
Severe diagnoses being missed or misjudged A relative described an experience of the patient with advanced cancer not getting chemotherapy
for cancer as planned:
‘I still wonder, why didn’t they start the treatment? My dad asked them repeatedly when it would
start; he trusted the doctors. // At one of his late consultations, the doctor admitted that they
had planned for chemotherapy and that there had been plenty of time for chemotherapy, except
they had made all these mistakes.’ (2)
A patient having a severe blood disorder, who was at risk of abnormal bleeding, reported that her
test results had been unknown for several years:
‘The test results from my blood sample were 54, while reference values were 165–387.’ (15)
Patient harm from mistakes and incidents A concerned relative reported that during hospitalization, her elderly parent had fallen and hit her
head so badly that she later died. The patient was treated with Warfarin, a blood thinning
medication, and eventually died from injuries caused by the fall:
‘If there had been a correct risk assessment in relation to my mother’s impaired health, low blood
pressure and medication, she would probably be alive today.’ (131)
Lacking information on healthcare A relative reported communication problems regarding information and advice:
‘At a consultation with doctor x, she thought that I was awkward, being a relative asking too
many questions all the time about my father and why he didn’t get the treatment.’ (2)
A patient reported not getting information regarding test results or treatment plans when
contacting healthcare services. No one could answer the patient’s questions:
‘The doctor told me to call his secretary and then he would call back immediately. Now three
months have passed.’ (123)
Insufficient coordination A patient reported problems with getting the local primary healthcare centre to issue the medical
certificate she needed for her sick leave:
‘I need a medical certificate for my sick leave because of my back problems. Since I’d been at the
specialist unit, my GP referred me to that specialist for the certificate, and the specialist referred
me back to the GP.’ (142)
Being ignored A patient visiting a clinic for a skin lesion reported a situation where he felt ignored by a
healthcare professional:
‘She throws a very nonchalant glance at my lesion and says to me that it is a totally normal age-
related change and nothing to bother her for. // With a harsh tone she says, ‘If we were to treat
such changes, we would drown in such matters’.’ (57)
Being treated with disrespect A close relative described being mistaken for a patient with dementia and being locked in a unit.
At first, he was surprised and could not make sense of what was happening. When he realized
that he had been taken to the wrong place, the staff refused to allow him to leave. Afterwards,

Table continued
560 Råberus et al.

Table 2 Continued

Subtheme Extracts from patients complaints

the man was shocked that he had been mistaken for a patient with dementia and locked in the
unit:
‘I’ve never felt so disrespected in my life.’ (155)
Healthcare without respect for the patient’s views A patient with a strong fear of childbirth together with the midwifery staff and the physician
made a birth plan. She was guaranteed a caesarean section, should the childbirth become
traumatic. The woman experienced this situation, and although she was in a panicked state, she
reported feeling completely ignored and having to carry out a vaginal delivery. The woman and
her partner were upset by this traumatic experience:
‘If I had had the caesarean section when I wanted to, the panic would have been avoided and I
would have been able to participate in my son’s birth.’ (16)
Being overlooked by healthcare professionals A patient with a mental health disorder reported that health professionals did not maintain
secrecy. A physician called an authority without the patient’s consent:

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‘I got furious, as he would not admit to wrongdoing.’ (80)

treatment plan was vague or inadequate. Sometimes, patients Discussion

reported difficulties in asking questions and problems in pathways
The patient complaints in this study reported problems regarding
to receiving more information. Communication problems were also
access to healthcare services, contact within healthcare services and
reported to result in ‘insufficient coordination’ of healthcare.
pathways to obtaining the necessary healthcare. Problems regarding
Ineffective communication caused flaws in cooperation between dif-
the quality of healthcare and patient safety were also reported, with
ferent healthcare organizations, between units or in specific patient
some patients suffering effects from mistakes and incidents. Overall,
situations. Problems with coordination and communication between
communication problems were observed more or less in almost
units resulted in patients suffering from gaps in care, not getting the
every patient complaint. Finally, a small number of complaints
help they needed.
reported healthcare options being pursued against the patient’s
wishes; however, these reports are remarkable and particularly
noteworthy.
Attitudes and approaches The analysed complaints emphasize patients’ vulnerability, as
Healthcare professionals’ attitudes and approaches were a common evinced in the recurring issue of patient exposure and vulnerability.
source of the complaints, reported as experiences of patients ‘being Vulnerability occurred in encounters with healthcare professionals,
ignored’ or ‘being treated with disrespect.’ where such vulnerability could increase or decrease [21]. Patients
Healthcare professionals’ attitudes were described as making are generally vulnerable due to a lack of power and, for instance,
patients feel ‘ignored’ or being met with non-chalance. Patients fear, worry and pain. Vulnerability is related to one’s bodily state
reported, for example, not being seen or taken seriously, or feeling and can be enhanced by injury or illness. This context provides an
mistrusted or insulted. In different ways, the complaints illustrated important background for understanding that ‘getting the fit right’
experiences of healthcare professionals not appearing to pay atten- for each patient requires that the healthcare be in tune with such
tion to the patients’ needs. complexity. In other words, patients may be on a spectrum where,
There were also reports of patients or relatives ‘being treated they sometimes require autonomy and a high degree of personal
with disrespect,’ making them feel offended or humiliated. Patients agency; sometimes need support for decisions; and sometimes must
or relatives described being disrespected in various ways and feeling be passive and dependent on the professional, needing decisions to
rushed or dismissed by healthcare professionals. be made for them, with each case depending on the degree of vulner-
ability and exposure. Moreover, this complexity concerning vulner-
ability can be understood within the view of patients’ dignity.
Healthcare options pursued against the patient’s Delmar [22] highlights the complexity of dignity in healthcare.
wishes Thus, nurses and healthcare professionals upholding dignity in care
A small number of complaints involved going against the patient’s are obliged to balance patients’ expectations and values, sometimes
wishes. These were examples of ‘healthcare without respect for the allow patients to have a voice in relation to treatment and care and
patient’s views’ or healthcare where the patient was ‘overlooked by at other times support them and meet them in vulnerability. Patients
healthcare professionals.’ want to be taken seriously, receive respect and preserve their dignity
Most of these complaints were related to ‘healthcare delivered as the masters of their own lives, but it is important to acknowledge
without respect for the patient’s views.’ There were reports on agree- the vulnerability and exposure of the patient in healthcare. Thus,
ments not being followed through or patients being coerced to agree achieving the right balance may mediate the issues that lead to
to aspects of healthcare that contradicted their needs and wishes. complaints.
There were also complaints about ‘patients being overlooked by The attitudes and approaches of healthcare professionals are of
healthcare professionals,’ for example, when confidentiality and utmost importance and seem to colour the depths and details of
anonymity were not maintained. Patients with psychiatric illnesses complaints. In the present study, shortcomings in attitude and
seem to be a particularly vulnerable group, as complaints regarding insensitive communication were reported; they were found to
decisions being taken against their wishes or without their participa- decrease patient satisfaction with care and sometimes even risked
tion were common. patient safety or added to the patient’s suffering. Communication
The nature of patient complaints • Patient satisfaction 561

failure has been linked to problems such as patient safety and poor to the situation and can fail to communicate effectively in terms of
patient experiences [23, 24]. Important steps towards effective com- their tone. Consequently, the attitudes and approaches of healthcare
munication are healthcare professionals’ attention on how informa- professionals are critical. Strategies for a more patient-centred per-
tion is understood by patients [25]. The approach to communication spective can be beneficial, but our findings show that there are gaps
and tone with patients are imperative for the quality of healthcare. in the centring of patients. Although the impact of patient-centred
This is against the backdrop of the long-standing policy of patient- care has been researched for several years, guidelines on how to
led care. The model of patient-centred care emphasizes patients’ implement and sustain such care are lacking. Developing more
experiences, values, needs and preferences in the planning, coordin- patient-centred care may improve patient–provider communication
ation and delivery of care [26]. Strategies like patient-centred care and increase patient satisfaction with healthcare, both in medical
can give patients more choices and a voice in their own healthcare consultation and nursing care. Yet our findings demonstrate that
[27]. In patient-centred care, the relationship between the patient patient vulnerability and meeting patients’ needs are complex issues
and healthcare professionals is central. There are benefits to more that involve more than simply ‘giving more choice.’ Further research
patient-centred care, and positive patient outcomes have been is needed into how such healthcare can be put into clinical practice
demonstrated, for example, in terms of increased patient satisfaction with policies and guidelines regarding the quality of healthcare that

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[26]. However, our findings suggest that more is needed beyond pre- can do justice to patients’ preferences and views in a way that is also
sent attempts to apply patient-centred care. The results highlighting sensitive to the dynamic and changing context of care.
the significance of attitudes and approaches reveal a situation that
remains professionally focused and not patient-focused. To gain a
more patient-centred healthcare, changes in professional’s attitudes Funding
and approaches are needed. To decrease patient’s vulnerability, This work was supported by the Committee for Human Rights, Region
healthcare professionals should act ethically and be directed towards Västra Götaland, Sweden.
patient’s experiences and needs [21]. A future challenge in health-
care is continuity of professionals, influencing the cooperation
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