Ever since To Err is Human did patients really start to care about the quality of care they received from their physicians, hospitals, and healthcare organizations. However, healthcare organizations had already recognized the importance of patient satisfaction several years earlier. Many organizations started measuring patient satisfaction as a way to judge the perceptions of how their patients viewed their experiences while under their care. There are many facets to measuring patient satisfaction but to date the concept of learned helplessness has not been incorporated into the mix. Learned helplessness is a phenomenon occurring in many places in our society. It affects how we work, interact with others, conduct our business, and employ our thoughts and views on healthcare. When experience with uncontrollable events leads to the expectation that future events will also be uncontrollable, disruption in motivation, emotion, and learning may occur. That phenomenon has been called learned helplessness (Cemalcilar 2003). Armed with a better understanding with how learned helplessness plays a role in patient satisfaction healthcare settings will be better able to alleviate this discomforting phenomenon and thus should raise patient satisfaction scores. This paper serves as a vehicle to investigate the concept of learned helplessness combined with a review of patient satisfaction and provide guidance for research to further our understanding of the relationship between the two.

Literature review:

Learned helplessness came about by accident in 1965 by Martin Seligman and his team while studying the relationship between fear and learning. Seligman observed an unexpected behavior while investigating Pavlov’s theory on stimulus and response. Seligman didn’t pair the bell with food but rewarded the dog with a small shock while restraining the dog to keep it from running away. The researcher thought that the dog would experience fear after hearing the bell and would try to run away or display some other type of behavior. After this the dog was placed into a box with two compartments divided by a low enough fence that the dog could see the other side and escape if the dog so desired. To their amazement, after the bell was sounded the dog didn’t try to run away but instead just laid or sat on the one side of the box. The researchers repeated the test but instead of sounding the bell they gave the dog a small shock. As was the case with the bell the dog decided to stay on its initial side of the box. The test was repeated with a dog that had never been subject to any of the previous experiments and when given the shock the dog took flight and jumped over the small fence to escape. What was decided was that the first dog, while being restrained, learned that trying to get away from the shock was pointless and the dog had no control over its destiny and was therefore helpless. Some researchers have contended that the dog just thought he was being punished for some act of wrongdoing or that the end of the pain from the shock was indeed the reward. However, this behavior has been used in a variety of situations which will be explained here in an effort to learn more about this phenomenon.

Learned helplessness has detrimental effects on children. They develop a lack of self-confidence in challenging tasks which result in deterioration of performances (Dweck, Davidson, Nelson, & Enna, 1978). These children do not develop good problem solving strategies and can suffer from lack of attention and think that all of their efforts are fruitless. Children like this are often held back a grade in an effort to bolster their social and academic skills. In the end, they get a message that they are worthless and hopeless (Berger, 1983). These children may be inadequately prepared to take on new learnings and perform out of the ordinary tasks. Failure become synonymous in these children’s vocabulary and repeated efforts may do little to change their outlook. In Erikson’s view, he suggests that children with few successes will become inferior which leads them to have a low self-esteem (Berger, 1983). Most learned helpless students give up trying to gain respect through their academic performance so they turn to other means for recognition. They may become the class clown, bully or tease. When they begin adolescent years they try to gain respect through antisocial behaviors (Berger, 1983). With learned helpless children, competence is almost entirely destroyed. They lose confidence within themselves because they experience failures, leading them to believe they are failures. They might feel competent about something at first but if they fail in that activity they won’t bother to try it again for fear of failure. Autonomy is also faint in a learned helpless student’s life. They feel as though they have no control over their environment because no matter how hard they tried in the past, they never succeeded. As for relatedness, learned helpless students feel as though they don’t belong because they believe that they don’t relate to the environment. This is why they become the class clown, bully or tease in order to get their recognition. These results may include becoming an antisocial individual during their adolescent years or earlier. These three factors are all detrimental to an individual’s growth and development in our social world today. There have been a few scales conducted and measured trying to use this construct in a variety of situations. The majority of these studies utilized learned helplessness as a secondary construct in explaining either complaint behavior (Lee and Soberon-Ferrer 1999) and measuring the relationship between empowerment and learned helplessness (Campbell and Martinko 1998). The study showed that there were many differences between empowerment and learned helplessness. Another study was conducted in a hospital setting with a reported reliability of 0.85. It had a positive relationship with Beck’s hopelessness scale (r=.252) and a negative correlation with Rosenberg’s Self-Esteem scale (r=-.622) (Quinless 1988).

Another way it can affect people is through different emotions such as pessimism, futility, risk aversion, depression, and self-esteem. It has been defined in people as a state of which the consumer cannot control their destiny or outcomes and therefore relinquish control over a certain situation.

What research to date has been conducted to study patient behavior with learned helplessness? Raps et. al (1982) found that the longer a patients length of stay was the worse the patient performed on cognitive tasks that index learned helplessness. First, they determined this because of a perceived loss of control by the patient. Second, increased hospitalization resulted not only in increased deficits but also in increased vulnerability to identical deficits produced by minimal amounts of uncontrollable noise, suggesting that the process underlying the deficits in the no-noise conditions is learned helplessness produced by hospitalization. Third, increased hospitalization disrupted performance at the problem-solving tasks, but not at the verbal intelligence test-replicating the previous results from laboratory studies of learned helplessness and suggesting that the deficits of our subjects were not a general deterioration but instead a more specific difficulty with new learning (Raps et al. 1982). Fourth, increased hospitalization produced increased depressive symptoms that covaried with poor performance both across and within conditions. This pattern suggests again that perceptions of helplessness caused the observed deficits, since depression involves a diminished sense of efficacy (Raps et al. 1982).

Faulkner (2001) set out to investigate the relevance of learned helplessness and learned mastery theories in the respective development of dependence and independence in older hospitalized people. Faulkner’s experiment shows how an exposure to uncontrollable or disempowering circumstances potentially places patients at risk of developing learned helplessness. This condition has the potential to retard self-care performance in the absence of supervision, direction, or active personal assistance thus rendering patients dependent (Faulkner 2001). Moreover, this dependence may not remain specific to the task within which LH was induced, but may generalize to affect patient performance in other activities. To date the accepted scale to use when measuring learned helplessness is the LHS scale developed by Quinless and McDermott-Nelson.

A conceptual definition is necessary in order to further explore this phenomenon. Learned helpless can be defined by a state in which a person thinks that they cannot control their own destiny and the life experiences which happen to them. This definition incorporates the key elements found throughout the research: loss of control, depression, low self-esteem, pessimism, and defeat.

Learned helplessness can have the potential for explaining some variation in patient satisfaction scores. In order to further explore how the two are interrelated, an investigation into patient satisfaction must be employed.

Patient satisfaction:

With the effectiveness of medical care being increasingly measured according to economic as well as clinical criteria, the inclusion of patients’ opinions in assessments of services has gained greater prominence over the past 25 years (Sitzia & Wood 1997). As health care budgets come under scrutiny, so consumers in the West have become more critical of the health care provided, organizing and claiming rights as active participants in the planning and evaluation of health services (Sitzia & Wood 1997). An increase in interpersonal relationship interest sparked the development for a need to understand the patient-physician relationship which gave rise to patient satisfaction measurement. Consumer advocate groups such as the National Consumer Council produced Patients’ rights, which influenced the rise of consumerism in healthcare. The term patient’s rights became the rallying cry for Patients to have more control and say about the care that was extended to them. What then determines what patient satisfaction is? Linder-Pelz (1982) approached a definition of patient satisfaction through five social-psychological variables proposed as probable determinants of patient satisfaction with health care. These are outlined as: Occurrences-the event which actually takes place, and perhaps more importantly, the individual’s perception of what occurred; value–evaluation, in terms of good or bad, of an attribute or an aspect of a health care encounter; expectations–beliefs about the probability of certain attributes being associated with an event or object, and the perceived probable outcome of that association; interpersonal comparisons–an individual’s rating of the health care encounter by comparing it with all such encounters known to or experienced by him or her; and entitlement–an individual’s belief that s/he has proper, accepted grounds for seeking or claiming a particular outcome. Ware et al. (1983) gives a more definitive taxonomy with eight dimensions: interpersonal manner–features of the way in which providers interact personally with patients (e.g. respect, concern, friendliness, courtesy); technical quality of care–competence of providers and adherence to high standards of diagnosis and treatment (e.g. thoroughness, accuracy, unnecessary risks, making mistakes); accessibility/convenience–factors involved in arranging to receive medical care (e.g. waiting times, ease of reaching provider); finances–factors involved in paying for medical services; efficacy/outcomes of care–the results of services provided (e.g. improvements in or maintenance of health); continuity of care–constancy in provider or location of care; physical environment–features of setting in which care is delivered (e.g. clarity of signs and directions, orderly facilities and equipment, pleasantness of atmosphere); and availability–presence of medical care resources (e.g. enough medical facilities and providers). CMS has mandated the HCAHPS measures of patient perception of quality of care as a condition of Medicare participation (Griffith & White 2007). CMS (Medicare) states “the supplier shall conduct beneficiary satisfaction surveys and make the results available upon request and/or listed on their Internet website (if applicable). The supplier shall document and review on a quarterly basis a percentage of beneficiaries satisfied with services.” These surveys include questions that are divided into five groups: Your care from nurses, Your care from Doctors, The hospital environment, Your experiences in the Hospital, When you left the Hospital, Overall rating of the Hospital, and Demographic questions. These questions must be incorporated into commercial patient satisfaction surveys and publicly reported. In some cases referring physicians may act as agents for their patients and are concerned with clinical outcomes, patient satisfaction and cost. This is important because if they are not satisfied with their patient’s responses, they may divert their patients elsewhere.

However there are some concerns for those that don’t buy into patient satisfaction scores. These fall into the category of social-psychological artifacts. LeVois et al. (1981) states that “Social desirability response bias” argues that patients may report greater satisfaction than they actually feel because they believe positive comments are more acceptable to survey administrators. Similarly, “ingratiating response bias” occurs when patients use the satisfaction survey to ingratiate themselves with researchers or medical staff, especially if there are any reservations over the anonymity of respondents (Sitzia & Wood 1997). Why then study patient satisfaction?

Typically patient satisfaction surveys are after the services have been rendered and the patient has left the hospital or physicians office. Most of the surveys use a 5 point Likert scale with 5 indicating excellent or highly satisfied and 1 being poor or highly dissatisfied. Most managers think that getting an average of 4s is very good or good enough and trying to achieve a 5 rating is too costly or time consuming. This is not the case. Many managers also think that they should focus on unsatisfied customers but research has shown that no matter how much time, effort, and money they invest, there will always be a small percentage of patients that are dissatisfied. Managers should then focus on moving those four ratings to fives. When it comes to customer loyalty, “excellent” has a different meaning from the other rating categories (Otani et al. 2009). Highly satisfied customers are the ones that are loyal and return for their next encounter or recommend others to the same physician or facility. This usually comprises of about 75% of the physicians business so it is imperative that they keep this group happy and highly satisfied. In an emerging competitive market such as healthcare, managers should focus on achieving excellent ratings to distinguish their organization from others (Otani et al. 2009). Patients that are merely satisfied will seek care elsewhere and look for other providers. Even though the cost of switching hospitals is quite high, patients have more choices now than they did in previous eras. What are some other reasons to highly satisfy these patients? Satisfied patients tend to comply with prescribed medical treatments (Ford, Bach & Fottler 1997). Due to an increase in chronic conditions, it is more imperative that patients follow the treatment process prescribed. This can reduce length of stays and lower readmission rates thus reducing costs. Also, it decreases switching. When a patient changes physicians, he or she may be required to retake tests, which increases the patient’s costs and may hurt the patient (Otani et al 2009). Another factor is patient satisfaction is now considered a key part of the healthcare quality improvement initiative (Shortell and Kaluzny 2000). Many managed care organizations use patient satisfaction data to determine reimbursement rates to healthcare providers, and many leading companies will not contract with health plans that do not require a patient satisfaction survey. Providers with positive patient satisfaction survey results may receive more financial incentives than providers with poor patient satisfaction survey results (Kongstvedt 2001). In addition a 1 standard deviation point increase in the quality of pt/physician interaction equals a 35% lower chance of a patient complaint for the primary care physician, and a 50% lower chance of a patient complaint for a specialist (Saxton et al. 2008). Saxton (2008) also reports that a one standard deviation decrease in patient satisfaction equals a five percent increase in the physicians risk management. Compared to physicians in top satisfaction scores: Physicians in middle 1/3 of scores had malpractice lawsuit rates 26% higher while Physicians in bottom 1/3 of scores had malpractice lawsuit rates of 110% higher. According to Saxton (2008) the top five patient priorities are: Response to concerns/complaints during stay, Degree to which hospital staff addressed patient’s emotional needs, Staff effort to include patient in decisions about their treatment, How well the nurses kept the patient informed, and Promptness in responding to the call button by the patient. One issue not investigated thoroughly is the billing activities of the hospital or caregiver. Richard Clarke, HFMA CEO and President has stated “the best care, and great customer service provided during the patient’s hospital encounter can be destroyed quickly by confusing, complicated, or incorrect billing afterwards” (Swayne et al. 2008). According to Swayne (2008, the top five hospital bill features that irritate customers the most are: confusion about what the patient’s insurance company has paid, confusion about the balance the patient owes the hospital once the insurance company pays its share, use of medical terminology that the patient does not understand, sending a bill to the patient before the insurance company has processed the patient’s claims, and inability to determine exactly what services the hospital has provided and what the patient is being charged for the service. Follow-on activities are also another area that the physician or caregiver can alter patient satisfaction scores. Many providers think that once the patient is out the door the experience ends there. After a patient has been seen by a physician or is leaving the hospital after surgery, there is a likely need for further services: a child with an ear infection has to return in 10 days for another check-up to make sure the infection is no longer present; after hip surgery a patient may need to be relocated to a rehabilitation facility to learn to walk again (Swayne 2008). All of these additional services are value adding service activities. All of these factors play a role in learned helplessness as the patient may become frustrated by not having an excellent experience throughout the visit or after the visit.

Proposed study:

This paper shall utilize the current learned helplessness scale (LHS) and apply it to see how it moderates patient satisfaction scores.

Method of study:

The proposed model for this study is:

Patient Satisfaction Scores

Internal State of patient

Patient Experience

Learned helplessness

Learned helplessness

This research was consistent with the often used S-O-R paradigm. This paradigm assumes that environments contain stimuli (Ss) that cause changes to people’s internal or organismic states (Os), which in turn cause approach or avoidance responses (Rs) (Mehrabian and Russell 1974). It is anticipated that higher levels of learned helplessness will negatively impact patient satisfaction scores. The area most anticipated are those consistent with loss of control in fulfilling the needs of the patient, like care from the nurses, care from the physician especially in information sharing, and billing issues from either the hospital or the insurance company. The construct will be viewed as a moderator. “In general terms, a moderator is a qualitative (e.g., sex, race, class) or quantitative (e.g., level of reward) variable that affects the direction and/or strength of the relation between an independent or predictor variable and a dependent or criterion variable. Specifically within a correlational analysis framework, a moderator is a third variable that affects the zero-order correlation between two other variables. … In the more familiar analysis of variance (ANOVA) terms, a basic moderator effect can be represented as an interaction between a focal independent variable and a factor that specifies the appropriate conditions for its operation.” (Baron & Kenny 1986).

Data collection:

Data collection shall be the most challenging facet of this study. It is important to gather rich data that will either support or disprove the theory that learned helplessness lowers patient satisfaction scores. A large enough sample is to be gathered in order to fully demonstrate this phenomenons capability. The LHS will be distributed along with the chosen hospitals patient satisfaction survey and patients will be asked to complete them. It may be necessary to delay the distribution of the survey so the patient has ample time to be contacted or experience learned helplessness form billing issues that may arise. After a sufficient number of surveys have been returned to the author, statistical regression methods will be employed to assess statistical significance as it relates to learned helplessness and patient satisfaction scores. Different factors can be cross-tabulated to see if there are any generalized effects on the scores like age, race, financial, and educational positions. Model fit could be assessed using SEM or other methods to ensure proper allocation and model assessment.

Limitations

As stated before data collection shall be difficult in performing this study. Hospitals may be reluctant to allow a researcher, independent of the organization, access to their patients and their satisfaction data. This reluctance could be over a variety of factors including patient privacy, fear of inappropriate scores released to the public, and a general distrust for academic research. It may be necessary to conduct this study as a joint venture so the hospital may learn from this study as well as the researcher. Another limitation is patient recall. This is always a factor since consumer recall plays a role in remembering perceptions, actions, and behaviors that occurred in the hospital or caregivers office. Since billing is an issue with learned helplessness, the delay in presenting the surveys may affect memory recall. The last limitation may be that of the construct being studied itself. Since there is little research on learned helplessness as it relates to patient satisfaction or patient experience it may be difficult to determine how strong a score on the LHS scale must be to fully realize an effect on patient satisfaction.

Conclusion:

This paper has outlined the construct of learned helplessness and how it potentially could interact with patient satisfaction scores. Patient satisfaction scores are of the upmost importance to hospitals and caregivers as it affects their quality ratings, their allocation from CMS, and their reputation in general. While this project is a major undertaking, the author feels that it is worthy of such time and effort as patients and caregivers seek to further understand the patient experience in healthcare settings. This paper has outlined a course of action and while this project needs to be further investigated, it lays the necessary framework for a study worthy of journal submission. Future research could fully implicate different ways that learned helplessness is formed in different healthcare settings allowing for richer analysis into how patients react to different perceived outcomes. Hospitals and caregivers should be able to use information from this study to redesign their patient satisfaction surveys to allow them to gather richer data and use this to improve satisfaction scores which ultimately affect the bottom line. In this new age of healthcare reform, it is imperative that healthcare organization strive in every effort to raise the bar of patient outcomes, not only physical outcomes but mental outcomes as well.