Enhancing Pediatric Satisfaction in Healthcare Services: An Integrative Review

Introduction

Patient satisfaction is defined as “the degree of agreement between the patient’s expectation of the health care experience and his/her perception of the level of care he/she actually receives.” ¹ Indeed, patient satisfaction is a personal evaluation of health care services and providers, but it is incorrect to consider all the information obtained from patient surveys as equivalent to patient satisfaction. ² Although satisfaction assessments are sometimes criticized for not fully corresponding to objective reality or the perceptions of care providers or managers, these assessments provide a unique strength: They add new information to the patient satisfaction equation. ³ This information allows health care providers to understand the perspective of patients and gives them a sense of participation in their care. It also enables the identification of existing problems during the care process, leading to the improvement of the quality of care and aiding in the evaluation of health services as a source of information related to health planning.^4,5

We believe that differences in satisfaction significantly reflect the realities of care. These differences also reflect personal preferences as well as patient expectations. Therefore, the patient satisfaction score serves as both a criterion for evaluating the quality of care and a criterion for meeting the patient’s expectations, which informs the scoring. This distinction is important for studies that attempt to use satisfaction assessments as a source of information about specific aspects of care.^6,7

The nature and number of dimensions of patient satisfaction are important issues for care providers. Various characteristics such as communication skills, workload, time constraints, attitudes of health care professionals, patient expectations, and the influence of organizational factors are of high value in the discussion of patient satisfaction, particularly in studies focusing on adult populations.^8,9 Qualitative, quantitative, and mixed approaches have examined this issue from various perspectives, highlighting the complexity of the challenges and efforts to find effective solutions.^{10 -12} Previous research has addressed specific challenges and their underlying causes in adults, proposing strategies to enhance patient satisfaction.^{13 -15} However, there has been a scarcity of studies focusing on children. Moreover, in most traditional studies, surveys or questionnaires are typically administered by parents or family members, who play crucial roles in ensuring the health of their children.^11,16 Yet, it is evident that in most studies, children’s views are ignored or sidelined. Some studies that have specifically examined factors affecting child satisfaction from the children’s point of view have not thoroughly explored certain aspects, such as emotional well-being, communication preferences, and the degree of involvement in decision-making.^{17 -19} These aspects are critical to understanding how children perceive their care experience, but they are often overlooked in favor of more easily measurable factors, such as pain management or treatment outcomes. ²⁰ However, the participation of minors in decisions that affect them is a right recognized in the Convention on the Rights of the Child. In any case, if patients themselves are not satisfied, it cannot be assumed that the health facilities have fully reached their goal. Therefore, in this study, we intend to explain some of the key issues in child patient satisfaction by systematically reviewing and analyzing the content of studies and outlining the dimensions of child patient satisfaction for further investigation in the future.

Method and Materials

A non-experimental approach utilizing Broome’s integrative review method, combined with content analysis, was employed to integrate diverse methodologies, aiming to inform evidence-based nursing practice. The review focused on articles published between 2000 and 2024, organized into three phases: literature search, data evaluation, and data analysis and synthesis.^21,22

In the search phase, various online databases such as SID, Magiran, Ovid, Scopus, Web of Science, EBSCO-CINAHL Complete, ProQuest, Embase, and Medline were systematically searched using keywords like Patient Satisfaction, pediatric, Health Services Evaluation, Child Health Service, Health Services Research, and Patient experience. This systematic approach involved using search terms like (patient satisfaction* OR patient experience) AND (pediatric* OR child health service*) AND (health services evaluat* OR health services research) to retrieve relevant articles from different departments of children’s hospitals, covering a range of patient satisfaction concepts.

Inclusion criteria required research articles written in English or Persian, studies focused on factors influencing pediatric patient satisfaction with healthcare services, and articles published between 2000 and 2024. Articles lacking full-text access or with a quality evaluation score below 50% were excluded.

In the data evaluation phase, multiple appraisal tools were applied to assess study quality, acknowledging the complexity of evaluating diverse primary sources. The challenge of applying broader quality criteria versus design-specific evaluations was highlighted, especially for non-empirical sources, which required different evaluation techniques. ²² Quality assessments varied based on the type of research, with theoretical sources evaluated for authenticity and methodological rigor, and empirical sources evaluated using tools such as Consolidated Criteria for Reporting Qualitative Research (COREQ) for qualitative research, CONSORT for randomized controlled trials, and STROBE for observational studies. Mixed-methods studies were evaluated using Mixed Methods Appraisal Tool (MMAT), and a 50% evaluation score criterion was consistently applied across all articles to ensure quality standards.

The data analysis phase involved organizing, coding, categorizing, and synthesizing primary sources to form a unified conclusion addressing the research problem. Despite its complexity, systematic analytical approaches were essential. Methods designed for mixed-method and qualitative studies, like the constant comparison method, proved effective for identifying patterns and relationships across diverse sources. This process involved data reduction, data display, data comparison, conclusion drawing, and verification. ²²

In this review, key factors and recurring patterns related to children’s satisfaction with healthcare were coded and grouped into themes that aligned with the research questions. These themes were refined for clarity and synthesized into a comprehensive report, linking the findings to the existing literature. ²³ Qualitative content analysis was selected for its systematic, objective approach to categorizing and quantifying textual data, making it well-suited for analyzing trends in child patient satisfaction. ²⁴ To ensure credibility, two independent researchers conducted the article search, qualitative evaluation, and analysis, resolving discrepancies through collaboration and reaching consensus (Figure 1).

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Figure 1.

Diagram of the inclusion and exclusion of the analyzed articles.

Results

In the initial search of databases, 2178 articles were found. After removing duplicates, screening articles with summaries, applying inclusion and exclusion criteria, and evaluating article quality using appropriate tools, a total of 146 articles were selected for content analysis (see Figure 1). These included quantitative and qualitative articles conducted in the pediatric healthcare settings. Among these, 56 articles were cross-sectional studies, 30 were semi-experimental articles, 10 were RCT studies, 24 were cohort and retrospective articles, 21 were qualitative articles, and 5 were mixed-method articles. Two independent researchers categorized aspects of satisfaction with hospital stays and extracted factors mentioned in the articles. These factors were then compared and placed under main categories and subcategories. Disagreements between the two researchers were investigated, and consensus was reached.

In this study, we examined a total of 146 articles related to patient satisfaction in children’s departments. Codes were extracted based on repetition in the text of the articles and then prioritized. A total of 48 factors, 32 subcategories, and 5 main categories were identified in the content analysis. The main categories, presented here in order of frequency of mention, were hospitality satisfaction, treatment outcome satisfaction, staff satisfaction, hospital structure satisfaction, and parental satisfaction. Factors of interest commonly mentioned across the studies included “pain relief,” “availability,” “unfamiliar environment,” “behavior of the treatment team,” “communication and coordination among doctors, nurses, and other members of the care team,” “boring environment,” “information about the time of recovery and discharge,” “parental stress,” and “length of stay.”

Fifty-one of the studies were conducted between 2019 and 2023, during the COVID-19 pandemic. These studies revealed a significant shift in healthcare priorities, with stricter rules and regulations, increased stress among parents and staff, and disrupted communication often taking precedence over typical concerns like the food menu.^25,26 In addition, during the pandemic’s first year, personnel shortages in some children’s hospitals led to an increase in negative experiences for pediatric patients. ²⁷ These findings highlight how the unique challenges of the pandemic significantly impacted both patient care and satisfaction.

The Main Aspects of Child Satisfaction

Parental Satisfaction

Parental satisfaction plays a crucial role in children’s satisfaction, as children’s experiences are often mirrored in their parents’ expressions. When children see their parents looking angry or worried, they often feel anxious and fearful. Therefore, improving parental satisfaction and bringing smiles to their faces can help calm the child. Parental satisfaction is also paramount in the treatment process, follow-up care, treatment outcomes, and ultimately children’s satisfaction. Unfortunately, in some treatment centers, parental satisfaction is prioritized over the child’s satisfaction. Compliance with treatment in childhood illnesses hinges greatly on the satisfaction of both children and parents. Factors influencing the satisfaction of children and parents are often closely aligned. Parental satisfaction in studies is influenced by several factors, including the knowledge and skills of healthcare staff, communication abilities, waiting times, treatment results, length of hospitalization, and severity of illness. For instance, lower satisfaction has been reported in studies involving chronic diseases. Additionally, demographic factors such as gender, insurance coverage, social support, and marital status can also affect parental satisfaction. However, factors such as race (being white or non-white) were not found to be related to parental satisfaction. Overall, parental satisfaction can be observed across various dimensions, including hospitality satisfaction, satisfaction with the hospital structure, satisfaction with staff, and satisfaction with the treatment process.

The dimensions of child patient satisfaction derived from the reviewed studies were depicted in Figure 2.

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Figure 2.

Dimension of pediatric satisfaction.

Discussion

In this Integrative Review, we aimed to explore the factors influencing the satisfaction of hospitalized pediatric patients, recognizing the dynamic nature of these factors over time. Despite 146 published studies spanning from 2000 to 2024 shedding light on common factors, it’s noteworthy that there was considerable heterogeneity in study objectives and data collection methods. Each study approached patient satisfaction uniquely, raising questions as to why hospitals, even within the same geographical area, employ varied factors for pediatric satisfaction assessment.

Nieman et al ³² revealed that demographic factors such as patient age, gender, race/ethnicity, and socioeconomic status do not significantly impact patient satisfaction in pediatric surgery departments. Conversely, a study focusing on adult patients underscored that variables like race, age, and gender do play a statistically significant role, with older, white, and male patients reporting higher satisfaction levels. Interestingly, income and language did not emerge as influential factors in satisfaction surveys. ³³ Additionally, the influence of social insurance on the satisfaction of parents of pediatric patients was evident. ³⁴ These discrepancies likely stem from differences in assessment methodologies and study designs. Various studies use different tools and scales to measure patient satisfaction, focusing on distinct aspects such as overall care, communication, or treatment outcomes. For example, some studies rely on standardized satisfaction surveys,^28,35 while others employ qualitative interviews or observational methods. ³⁶ Although the validity and reliability of these tools had been confirmed, they assessed child patient satisfaction from entirely different dimensions. For instance, the Children’s Satisfaction with Hospitalization Questionnaire (CSHQ), developed by Gómez-de-Terreros-Guardiola et al, ³⁷ emphasizes a one-dimensional approach to satisfaction, defining “hosting” as the most important factor in children’s satisfaction.

Additionally, the population being assessed—whether pediatric patients, their parents, or both—can influence the findings. Study types also vary, with some being cross-sectional, capturing data at a single point in time, and others longitudinal, tracking satisfaction over extended periods.^31,38 These methodological differences contribute to inconsistent findings across studies, making it challenging to generalize results or establish uniform criteria for evaluating pediatric patient satisfaction.

The findings from our review highlight various factors influencing patient satisfaction, including hospital structure, hospitality, staff interactions, and treatment outcomes, though these factors impact satisfaction in different ways. Efforts to enhance satisfaction levels have often targeted individual aspects of the patient experience, which reflects a somewhat one-dimensional perspective on pediatric patient satisfaction. Such an approach risks overlooking the multifaceted nature of pediatric care, where emotional, psychological, and physical needs are intertwined. Additionally, the use of diverse assessment tools in pediatric departments has yielded varied results, complicating the ability to draw broader conclusions or implement standardized improvements. While these tools capture different dimensions of satisfaction, their inconsistent use raises concerns about their validity and reliability. It is essential that future research critically evaluates the effectiveness of these tools, ensuring they are both valid and reliable across diverse pediatric populations, to provide a more comprehensive understanding of patient satisfaction.

Hospital infrastructure emerged as a significant determinant of satisfaction, with facilities such as playrooms and cheerful environments significantly impacting children’s experiences. ³⁹ Other influential factors included the provision of amenities like TV rooms, music playback, and role-playing. ⁴⁰ Interestingly, the use of clowns to create a jovial atmosphere for children yielded positive experiences, although it led to decreased satisfaction among parents in some instance. ⁴¹

Healthcare staff also played a pivotal role, with their behavior, emotions, and job satisfaction influencing the quality of care and pediatric patient satisfaction. Studies have shown that the job satisfaction of nurses is significantly associated with the quality of care provided to pediatric patients. ⁴²

Another notable observation was the assessment of patient satisfaction from the parents’ perspective, which highlighted differing views in certain areas, though not explicitly contradictory. ⁴³ While parental satisfaction is strongly correlated with child satisfaction, as parental behaviors and emotions significantly influence their children’s experiences. ⁴⁴ These differences suggest that unresolved issues involving parents can impact children’s reactions. Future studies should explore this dynamic relationship between child and parental satisfaction through more comprehensive quantitative and qualitative research methodologies.

Treatment outcomes play a crucial role in pediatric patient satisfaction, as they directly impact the child’s health and well-being, as well as their overall experience during hospitalization. ⁴⁵ Clear and straightforward explanations of treatment procedures and expected outcomes to both the child and their parents are essential for ensuring understanding and cooperation.^46,47 When children and parents are well-informed about the treatment process, they are more likely to feel confident and satisfied with the care provided. Conversely, a lack of clarity or misunderstanding about treatment can lead to anxiety and dissatisfaction.

Furthermore, the encouragement of active participation from both children and parents in the treatment process can positively influence satisfaction levels. ⁴⁸ When children and parents are involved in decision-making and care activities, they feel empowered and valued, which enhances their overall satisfaction with the treatment experience.

Additionally, obtaining consent from children and parents and giving them the right to choose aspects of their care can contribute to satisfaction. ⁴⁹ When patients feel that their preferences and choices are respected, they are more likely to feel satisfied with their treatment. Moreover, follow-up care and support after treatment are essential for ensuring positive treatment outcomes and patient satisfaction. ¹ Providing clear instructions for post-treatment care, as well as offering ongoing support and monitoring, can help address any concerns or complications that may arise, leading to increased satisfaction with the overall treatment experience.

Overall, treatment outcomes are a critical component of pediatric patient satisfaction, and efforts to improve communication, participation, consent, follow-up care, and support can contribute to enhancing satisfaction levels among pediatric patients and their families.

Conclusion

In healthcare systems, where patient satisfaction directly impacts productivity, a comprehensive examination of pediatric patient satisfaction is crucial. Overlooking the satisfaction of child patients—who represent the future generation and shape the attitudes of subsequent generations—poses a significant challenge to healthcare systems. Focusing solely on obtaining consent from child patients in limited contexts risks neglecting other critical aspects of their satisfaction. Therefore, it is essential to identify all dimensions of pediatric satisfaction to strengthen hospital capabilities and enhance patient care.

This survey has identified key factors that support pediatric patients by improving hospital infrastructure and outlining strategies to boost child patient satisfaction. The findings of this study, along with the developed framework, offer valuable tools for measuring satisfaction in pediatric healthcare settings. Based on our research, we recommend that satisfaction assessment forms in children’s hospitals be divided into five sections: Parental satisfaction, hospital structure satisfaction, hospitality satisfaction, staff satisfaction, and treatment outcome satisfaction (Figure 2). This multifaceted approach will provide a more comprehensive understanding of pediatric patient satisfaction levels and enable tailored interventions to meet the unique needs of both children and their families. However, during disasters such as the COVID-19 pandemic, priorities of care may shift. In these situations, factors such as communication and stress reduction may take precedence over other areas, highlighting the need for flexibility in the approach to enhancing pediatric patient experiences during crises.

More in-depth studies investigating the nuances of pediatric patient satisfaction and exploring additional factors influencing their experiences are warranted. Furthermore, qualitative research methods can offer a deeper understanding of the emotional and psychological factors contributing to pediatric patient satisfaction. By continuously refining the understanding and measurement of pediatric patient satisfaction, healthcare providers can aim to deliver patient-centered care that addresses the evolving needs of young patients and their families.