Satisfaction with care received in health services has been an object of study and analysis for many years, and it is considered that users’ perception of this care is closely related to the quality, effectiveness, and efficiency of a service.1–3 Satisfaction is difficult to measure, among other things, precisely due to its complexity.4–8

The variables more frequently studied because of their possible association with satisfaction can be grouped into four main dimensions. The first one refers to the care received from the healthcare staff. A second group is related to care received from the remaining personnel (not health personnel). The third group of variables studied is related to the conditions and facilities of the service. Lastly, a fourth group of variables is related to the accessibility to the health services.9 In addition to these four aspects, the severity and the symptomatology presented by the patient have also been studied frequently due to their relationship with satisfaction.

No doubt, the set of variables that has received the most attention is included in the first category of variables. Among them, the patient–doctor relationship, for example, has been considered essential for patient satisfaction.10,11 Thus, when problems or difficulties arise in aspects such as communication with the healthcare staff, information received during the healthcare process, coordination, the participation of the family in assistential issues and in decision-making, the levels of user satisfaction are clearly lower.11–15

With regard to the second and third groups of variables, there have been many studies of variables, such as relationships with the staff, the physical conditions, and other organizational issues in specific hospital units, with low levels of satisfaction associated with poor ratings of these variables.2,16,17

With regard to the fourth group of variables, when accessibility to the service is deficient, the waiting times are long, the office hours limited, with long intervals before obtaining the results of diagnostic tests or specific interventions, long distances from the users’ home, etc., the users’ levels of satisfaction decrease significantly.14,18

Lastly, with regard to the severity of the disease, some investigators have found that higher severity of the disease is associated with a higher level of satisfaction with the care received.14

In the specific case of paediatric care, the parents usually present high levels of emotional alteration such as fear, anxiety, or stress,21,22 which could be associated with irritation, anger and fury. Although some authors have related satisfaction with diverse emotional alterations in the healthcare setting – for example, stress and/or anxiety is associated with lower levels of satisfaction19 – few studies have examined the relationship between satisfaction and emotional alteration in paediatric emergency services.

The goals of this investigation are, firstly, to determine the association between satisfaction with healthcare and anger in the parents of children attended to in healthcare emergency services on the one hand, and the association between the parents’ perceived severity of their children's health status and anger, on the other. According to the literature consulted, we expect to find that, at a lower level of satisfaction, there will be higher levels of anger in the parents, and that the more severe the child's situation, the higher the levels of emotional alteration could be and, therefore, of anger.

Secondly, we propose to determine whether different levels of severity in the children could explain diverse levels of anger in the parents. Our hypothesis is that, the higher the child's severity as perceived by the parents, the higher the parents’ levels of anger and annoyance.

Lastly, our third goal aims to determine which dimensions of satisfaction studied can better predict the presence of anger in the parents, also taking into account the minor's severity in this relationship. Our working hypothesis is that low satisfaction with the clinical staff could be one of the variables more closely associated with the presence of anger in the parents.

This is a cross-sectional descriptive study using a survey in a sample of randomly selected parents, whose sons/daughters were attended in paediatric emergency services.

In our results, we observed that the lower the paternal satisfaction with the care received in emergency services the higher the levels of annoyance and anger. This result is repeated both in global satisfaction and in specific satisfaction in the four dimensions considered. When focusing on the severity of the child's disease, we also clearly found a parallel tendency of higher levels of anger coinciding with higher perceived severity of the child. These results agree with those found in other studies that related to greater emotional alteration (for example stress, or anxiety) with higher levels of perceived severity by the parents.21

Perhaps the most relevant result of this study derives from the regression analysis carried out. Of all the aspects considered, low satisfaction with access to the paediatric emergency services seems to be the best predictor of the presence of anger. This variable is associated with diverse aspects that vary from the time it takes to travel from the family home to the health centre, the time until they are attended to after arriving at the emergency service, or more indirect aspects, such as the easy access with a private vehicle, etc. In fact, the waiting times – whether to receive attention, to obtain information or the result of medical tests – have been the object of study for some time, due to their importance in patient satisfaction or as a source of parents’ stress and emotional alteration.18,25–27

The next variable that best predicts satisfaction is perceived severity. This result – which is along the lines of the results of the correlation and the analysis of variance – indicates that parents’ perception of their children's severity of disease is one of the variables that best predict anger. This result deserves more attention in future research, because the effect of severity is probably mediated by contextual variables, the care received, or some other kind of emotional alteration, such as, for example anxiety or stress.14,21 Moreover, future studies should use a more robust indicator of the patient's severity, for example, that is provided by medical specialists or obtained by means of a reliable assessment instrument. In our case, the indicator we used, although it provides a subjective, direct, and personal rating by the parents, has the limitation of not being a robust measurement.

Regarding other indicators of satisfaction, satisfaction with the performance of the medical and health personnel has also been shown to be relevant. Thus, low satisfaction with these aspects doubtlessly predicts anger in the parents. As reported in other studies, when referring to stressors during paediatric care,21,26 some aspects, for example, the care received, communication with the paediatricians and other health personnel, and access to information are clearly associated with emotional alteration and, in our case, when they are deficient, to higher levels of anger.

Lastly, of the variables studied, satisfaction with the non-medical personnel and satisfaction with the facilities, the equipment, the waiting room, and other physical aspects of the healthcare setting were the worst predictors of the onset of parents’ anger. In other studies of diverse health services, it was found that issues such as comfort or the facilities were associated with good levels of general user satisfaction5,12,28; however according to our data, these variables did not predict anger in the population under study. Perhaps the relevance of these aspects is lower in our specific case, where the interaction with these professionals tends to be scarce and brief.

Limitations of the study include some characteristics of the sample with which we worked through the implications this may have. Our sample has a low percentage of parents with moderate or high anger scores. This could subtract clinical relevance from our study and suggested other studies that may focus on specific samples of parents with high levels of anger in these circumstances. It would also have been of interest to consider variables such as for example clinical severity of patients or waiting times because of the implications that they could have. Not having taken it into account requires that our results should be understood with caution and involves aspects of interest for future research.

To conclude, on the basis of our results it seems evident that in order to reduce the levels of parents’ anger in paediatric emergency services, accessibility to the service, interpersonal interaction, as well as some aspects of the professionals’ work should be taken into account.29 Aspects like the access to receive attention or communication with the personnel seems to be among the most important, like in primary care and paediatric hospital services. With regard to the work of the clinical staff and applied aspects, it may be appropriate to promote efforts aimed at improving communication, with initiatives such as the continuity of the same informer throughout the entire healthcare process, parents’ access to comprehensible health information, participation of the family in the assistential process and decision-making, or rapid and efficient attention to the patient's symptomatology and distress.

The authors declare no conflict of interest.