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Thursday 1 May 2008

Patient satisfaction with diabetes care
Author(s):

Hornsten, Asa PhD RN; Lundman, Berit PhD RN; Selstam, Eva Kihl RN; Sandstrom, Herbert PhD MD

Issue:
Volume 51(6), September 2005, p 609–617
Publication Type:
[ISSUES AND INNOVATIONS IN NURSING PRACTICE]
Publisher:
Copyright © 2005 Blackwell Publishing Ltd.
Institution(s):
Senior Lecturer, Department of Nursing, Umeå University, Umeå, Sweden (Hornsten)
Professor, Department of Nursing, Umeå University, Umeå, Sweden (Lundman)
Masters Student, Department of Nursing, Umeå University, Umeå, Sweden (Selstam)
Senior Lecturer, Department of Public Health and Clinical Medicine, Family Medicine, Umeå University, Umeå, Sweden (Sandstroms)
Correspondence: Asa Hornsten, Department of Nursing, Umea University, Umea, SE-901 87, Sweden. E-mail: asa.hornsten@nurs.umu.se
Accepted for publication 12 November 2004
Keywords: dissatisfaction, nursing, patient perspective, patient satisfaction, patient-centred care, type 2 diabetes
Abstract

Aim: The aim of this paper is to report the findings of a study that elucidated the experiences and reflections of people with type 2 diabetes about clinical encounters.

Background: Several patient satisfaction surveys have focused on privacy, cheerfulness and amenities rather than on how the care was delivered. A great deal of research has also focused on communication and various consultation styles, particularly within health promotion and diabetes care, but how these factors tie up with patient satisfaction has rarely been discussed. This study was performed in order to elucidate patients' perspectives about clinical encounters in diabetes care.

Method: Interviews were carried out during 2001 with 44 patients with diabetes. The transcribed interviews were analysed using qualitative content analysis.

Results: Five themes were connected to patient satisfaction and dissatisfaction, namely ‘being in agreement vs. in disagreement about the goals’; ‘autonomy and equality vs. feeling forced into adaptation and submission’; ‘feeling worthy as a person vs. feeling worthless’; ‘being attended to and feeling welcome vs. ignored’; and, lastly, ‘feeling safe and confident vs. feeling unsafe and lacking confidence’.

Conclusion: Despite efforts to individualize diabetes care and find ways to communicate with patients, many people have experiences of clinical encounters that they find dissatisfying. Experiences of dissatisfying encounters have elements that may threaten their perception of self and identity, while elements included in satisfying encounters are those characterizing patient-centred care.



Introduction

Type 2 diabetes is a chronic disease managed primarily by the affected individual, and therefore a cornerstone in care is a sufficient support for self-management (Anderson et al. 1995). In care of patients with type 2 diabetes, patient education has traditionally been considered to be necessary for self-management. Unfortunately, the effects of traditional educational interventions aimed at improved glycaemic control (and thus reduced risk for complications) have been reported to be discouraging in the longer-term (Norris et al. 2001). Self-management programmes have been reported to have a beneficial impact on at least psychological well-being and quality of life, both in the short- and in the long-term (Norris et al. 2001, Steed et al. 2003). Consequently, the focus in patient education has moved away from providing medical information by didactic teaching to assisting and strengthening patients to improve their self-management skills, self-efficacy and motivation (Snoek & Visser 2003).

Concepts such as compliance and adherence used in referring to the care of people with diabetes have increasingly been replaced by concepts such as empowerment and patient centredness, possibly owing to research findings that expectations of adherence from the healthcare team create an environment of frustration and poor communication (Anderson & Funnell 2000).

Background

The communication style of healthcare professionals with patients has frequently been studied and many researchers advocate a holistic or patient-centred dialogue which includes the individual illness experience (Anderson et al. 1991, Brown & Hanis 1995, Roter et al. 1995, Stewart 1995, Kinmonth et al. 1998, Woodcock et al. 1999, Little et al. 2001, Massad 2003). Brown and Hanis (1995) suggested a model of consultation which includes understanding the experience and expectations of illness, understanding the whole person and finding common goals, enhancing the relationship and using time realistically, all of which they define as a patient-centred consultation. Little et al. (2001) proposed that there is little empirical evidence from a patient perspective to support the model or to identify the components which are most important to patients. Studying patients' preferences for consultations, Little et al. (2001) found among patients in primary care that most preferred good communication, which included being listened to, exploration of concerns, requirements for information and the doctor–patient relationship. Second, they preferred a partnership that included finding a common ground, and reaching mutual agreement about ideas, the problem, and the treatment. Third, they preferred health promotion, meaning knowledge about how to stay healthy and reduce the risks of future illness, and actions taken towards such health promotion.

Kralik et al. (1997) found, in a study among female postoperative patients, that nurses were either engaged with their nursing care, which was perceived as positive, or detached, which was perceived by people to be negative. In a study, among insulin-dependent diabetes patients, Wikblad (1991) found that patients preferred to be responsible for themselves but needed support to accomplish self-care. The study further pointed out that patients preferred education at a minimum level but as a continuous process; also, education should be applicable in practice. In a study of patients with sore throats by Little et al. (1999), the strongest predictor of satisfaction was addressing patient concerns, which was closely linked to effective communication. The latter also reduced the risk for prolonged illness. According to Barry et al. (2000), consultations tend to neglect those aspects of communication that remain unspoken. Furthermore, Barry et al. (2000) reported that the patients' own concerns most commonly voiced in consultations were symptoms and requests for diagnoses and prescriptions. Common unvoiced concerns included patients' worries about what the future held; ideas about what was wrong; and information related to the patients' social context. Barry et al. (2000) concluded that patients' concerns not raised often led to problems such as major misunderstandings, dissatisfaction, unwanted treatment and non-compliance.

Several patient satisfaction surveys have focused on elements such as privacy, cheerfulness, amenities and availability of parking, rather than on how the care was delivered and what it aimed at. This has resulted in insufficient knowledge about why the care was satisfactory or not (see, e.g. Bechel et al. 2000). This is one argument for using patients' narratives about their experiences with clinical encounters to find out more about what patients with diabetes find satisfactory or not. Coyle and Williams (2000) argued that the research in this area needs to shift from satisfaction to dissatisfaction, since patient surveys are usually characterized by extremely high overall estimations and very few highlight dissatisfaction. In other words, the instruments are often insensitive in eliciting disappointment with or negative experiences in health care (Walsh & Walsh 1999, Coyle & Williams 2000). Furthermore, many patients may only express dissatisfaction under certain circumstances, such as when they believe there has been a failure in service provision and they are given the opportunity to voice and justify their dissatisfaction (Williams et al. 1998, Coyle 1999).

In the literature, there was no homogeneous definition of patient satisfaction, since satisfaction concerns various aspects of care or care settings, as well as care given by various professions. Satisfaction with care also concerns perspectives of people with various states or illnesses but also with different ages, gender and ethnicity, which make it difficult to interpret or to define patient satisfaction as a homogeneous concept. Wilkin et al. (1992), however, stated that patients' satisfaction with care represents a complex mixture of perceived needs, expectations of care and the experience of care. Eriksen (1995) defined patient satisfaction as patients' subjective evaluation of their cognitive and emotional reaction to the interaction between their expectations about ideal nursing care and their perceptions of the actual nursing care received. In several surveys, patients' satisfaction with nursing care has been viewed as a predictor of their overall satisfaction with care (Abramowitz et al. 1987, Idvall et al. 1997). Mahon (1996), in a literature analysis of patient satisfaction related nursing care, found that satisfaction and dissatisfaction exist as separate continua and are expressed in different terms. This is a limitation, and the challenge for future researchers is to explore satisfaction and dissatisfaction on the same continuum.

We performed this study, then, because we felt that despite much research into communication and various consultation styles in care and patient education, patients' views on these clinical encounters had rarely been investigated and therefore needed further elaboration. Furthermore, research on satisfaction with clinical encounters among outpatients, including patients with chronic conditions such as diabetes, is rare.

The study
Aim

The aim of the study was to elucidate patient experiences and reflections on clinical encounters as narrated by people with type 2 diabetes in Sweden.

Methods
Design

This study formed part of an intervention study. The data were collected in 2001 by interview.

Participants

Four of 15 primary healthcare centres were randomized to an intervention group. Patients were drawn from the four healthcare centres' computerized patient records. All Swedish-speaking patients at these four healthcare centres (except those suffering from severe illness) aged 40–80 years and diagnosed with type 2 diabetes during the previous 2 years were invited to participate in the intervention study. Patients from four other healthcare centres were invited to participate as controls. Altogether 201 patients were invited to participate in either the intervention or the control group. Ninety-seven did not respond or declined to participate, leaving 104 patients allocated either to the control group (n = 60) or to the intervention group (n = 44). The non-participants and participants did not differ significantly in age or gender or treatment, and those in the control and intervention groups were judged as similar from baseline data. The demographics of the interviewees are shown in Table 1.



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Table 1 Baseline demographic and clinical characteristics of participants (n = 44)

Interviews

The interviews consisted of narratives about the patients' personal understandings of illness (Hörnsten et al. 2004) and narratives and reflections about their experiences of care. In general interviews lasted from 60 to 90 minutes and were carried out in patients' homes, except for three interviews that were performed at the patients' workplace. The initial question asked was, ‘Please tell me about your experiences of encounters with healthcare professionals in diabetes care?’ The narratives were followed-up with comments and questions such as, ‘Tell me more about it!’, ‘How did you feel then?’ and ‘How do you reflect upon this?’

Ethical considerations

The study was approved by the ethical committee of the Medical Faculty, Umeå University. The participants were informed about the study and requested to participate by letter, and were asked to fill in and send back consent forms if they agreed to be contacted by telephone and interviewed in their homes.

Data analysis

The interviews were tape-recorded and later transcribed verbatim and analysed by qualitative content analysis, according to Graneheim and Lundman (2004). In this analysis, both manifest messages (i.e. messages close to the text) and latent messages (i.e. the underlying messages) are highlighted.

The method includes analysis in different steps. As a first step we combined the text from the different interviews into one text and divided this into the two interview areas mentioned above. The text about patients' experiences and reflections on encounters in diabetes care constituted the unit of analysis, which was read through in order to obtain a sense of the whole. Next, the text was read in detail and meaning units were identified and condensed in order to make the text shorter but retain its core messages. The condensed meaning units were then abstracted and labelled with codes, while considering the original text (e.g. how the experiences were reflected upon by the participant). The various codes were compared on the basis of similarities and differences, and sorted into schemes labelled as categories and subcategories constituting the manifest content.

In order to seek agreement between the researchers, the categories were further studied and discussed, which led to refinement of the scheme of categories, and also to the identification and formulation of themes, interpreted as underlying or latent messages of the abstracted categories.

Findings

The following five themes were formulated about experiences of clinical encounters with healthcare professionals, which were interpreted as either satisfying or dissatisfying experiences. Quotations have been added to give meaning to the text. The findings are summarized in Table 2.



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Table 2 Experiences of satisfying and dissatisfying clinical encounters

Being in agreement vs. in disagreement about the goals

Clinical encounters during which patients experienced professionals as being sensitive about and accepting of their (i.e. the patients') own goals, and also as trying to understand the patients' perspective (e.g. the reason for their limited resources, or the basis for their possible lack of motivation), were interpreted as satisfying. The following quotations are examples of being respected for one's own goals:

A strict diet is just not what I consider to be satisfying quality of life, and therefore I prefer to be on insulin. I told my doctor and diabetes nurse about it and they understood me, and support me in managing it in my way.

My view is that the body should manage diseases without medicines, and until now it has worked. The doctor has listened to me and respects [my opinion].

Interviewees also talked about encounters in which they felt that healthcare professionals viewed blood sugar levels as the supreme goal of the treatment, which was not always in agreement with patients' own goals or resources. They told of encounters during which professionals had stated their expectations and goals, e.g. lifestyle changes. Often these were viewed by patients as impossible to reach or even as undesired goals, and this type of encounter was then interpreted as dissatisfying. The following quotations are examples of having different goals:

The various doctors I've met during these years have had a lot of complaints about my lifestyle and [the fact] that I do not exercise…I know that very well, but they are just talking about my diabetes and the blood sugar, and forget my back pain and dizziness.

They check blood sugars and cholesterol frequently, but when I ask them to check my eyes they hesitate.

Being autonomous and equal vs. being forced into adaptation and submission

Satisfying clinical encounters with professionals were described as being characterized by empathy and as including an understanding of the work associated with self-management of diabetes. Terms such as ‘equality’ and ‘respect for own choices’ were used to describe satisfying encounters. The following quotations are examples of feelings of equality:

We started to get to know each other and could speak openly about various things. We told each other about mental as well as physical and other heavy aspects, since these things are connected…He didn't separate the disease and say that you have diabetes and must do this and this. I explained the problems to him and he really listened and learnt.

I believe in acupuncture, which is another kind of care that takes the whole person into account. I first hesitated, but later I told my doctor about that treatment and surprisingly she encouraged me to go on with it. And after that our relation reached another level, and I started feeling more respect for her.

Patients also talked about unsatisfactory encounters, which they thought were characterized by the professionals' efforts to reshape them into adapting a healthier lifestyle. Often they would view such efforts as demands for adaptation and submission, of which the following quotations are examples:

The healthcare centre, it's like a big joke, as I see it…I felt I was being blamed, and I felt a little sore when she kept on with her pointers. It's that way I experience the diabetes care of today, it is mainly pointers.

I am sad because the doctor has decided not to prescribe anything for me or give me advice, since he thinks I don't manage the diet well. He says that I should lose weight and cut down on my eating, and I have lost weight, but the blood sugar is still too high and I am so tired.

If I question what the doctor tells me, I don't get any nice consultations with him. He doesn't like the fact that I have my own theory about the best way of keeping my blood sugar low.

Feeling worthy as a person vs. feeling worthless

Patients who felt that their clinical encounters with healthcare professionals had been characterized by respect for their experiences of living with diabetes, and who they felt that the professionals viewed and respected them as persons with weaknesses as well as strengths, were satisfied. They also felt worthy as persons, and that they were not merely being treated as patients or cases. The following quotations are examples of positive experiences of encounters with healthcare professionals, including feeling respected and worthy as a person:

The district nurse has known my family for decades, and understands my situation, like my problems with walking, and that I can hardly empty the mailbox…She sees me as a human being and last month she provided me with a cycle exerciser, which I use regularly.

I have had the same contact for many years, and it's really nice to go for the check-ups. He has become more and more of a friend and asks me about my husband's health and other, more personal things.

Interviewees talked about dissatisfying clinical encounters that resulted in feelings of being worthless as a person. Professionals' desire to inform, advise and even rebuke patients in order to make them more aware of their ‘responsibilities’ and achieve glycaemic control was described as reflecting an authoritarian attitude, and as presenting the caregivers as having more ‘appropriate’ knowledge about the disease and treatment. Furthermore, patients sometimes told of encounters during which they had felt that professionals viewed the diabetes as more important and more interesting than themselves. These encounters were associated with feelings of being worthless and of not being respected, examples of which are given in the following quotations:

The doctor doesn't care about me, but he cares a lot about my disease. I feel that he uses standard words that are really impersonal and he doesn't care about me, not at all…nowadays doctors perform their medical work only, no more.

After those experiences, I doubt that those working within diabetes care really care for patients personally.

I told a doctor about what I thought was causing the diabetes, but he said that he had never heard anything so stupid. Now I have talked to another doctor in the hospital who confirmed what I said, and said that it could very well be true.

Being attended to and feeling welcome vs. ignored

Encounters with professionals who made patients feel attended to and who were also friendly and welcoming were seen as satisfying. They also engendered a feeling of trust, with patients experiencing the true meaning of cooperation, for example:

It was really nice to meet a doctor who listened in an interested way and who took me seriously. At that consultation I felt I was well cared for, which I don't feel at my healthcare centre, where most patients are viewed as something evil, disturbing the personnel in their paperwork.

Usually, doctors need evidence to believe in symptoms. It's not enough that I tell them. But that time I felt he believed in me and said, ‘I'm not giving up until I find out what you are suffering from’, and he did. I was helped by a new method of treatment…I must say that I really trust him and am grateful.

On the other hand, there were dissatisfying encounters, which patients described as being characterized by ignorance, including being treated unkindly or being made to feel unwelcome. They said that this type of treatment wounded and insulted them, exemplified in the next quotations:

As soon as I stepped into the room I noticed her gaze. They see me as a hypochondriac and don't understand my suffering…Later she said, ‘There are more people than you who need help’.

I have had a presentiment about it [having diabetes] and therefore I've tried to eat well, but I haven't yet been for a checkup. When I went for my 60-year checkup I told them [the professionals] about my suspicions, but they ignored me totally.

Being safe and confident vs. unsafe and lacking confidence

Interviewees said that they experienced a feeling of security, and that they felt safe and confident during the satisfying encounters, mostly in hospital settings and in research projects, while some did not have such satisfying experiences in primary health care. The next quotations are examples of encounters and situations where patients felt safe and confident:

I have participated in several research projects and feel that I am listened to differently than in regular care, and they are really experts in the field.

If he suggests a medical treatment I am satisfied, because I believe in pharmaceutical products. I am a scientist myself. If I get a prescription for the best medicine that has just been trialled in well-performed studies, I feel safe.

I don't rely on getting any help from the healthcare centre, but if I get severely or acutely ill and need hospital care, I'm sure I'll get satisfactory medical care.

Patients talked about dissatisfying encounters resulting in their feeling unsafe and lacking confidence. They described situations which they interpreted as related to professionals' inability to make them feel safe and confident. For instance, some were quite uncertain themselves and did not project any confidence, and patients described some as lacking competence and having antiquated views. Still other caregivers merely gave routine information which was not adjusted to individual needs. Consequently some patients described themselves as having more competence than the professionals, which made them less confident in getting the support they received, as in the following examples:

You know, the dietician I met, I'm sure she meant well, but she wasn't engaged and gave [not up-to-date] routine advice. What she had to say was nothing new to me. Why should I consult her?

I simply can't enter into a discussion with a doctor who lacks the latest knowledge about diabetes, although I am quite easy to please.

Discussion

In this paper, we do not distinguish between the care given by nurses and that given by doctors and other healthcare professionals since the patients' narratives concerned encounters with all kinds of healthcare professionals.

The theme about being in agreement vs. being in disagreement about the goals has been much studied previously, and our findings are in line with those of others. Sumsion and Smyth (2000) in a study of occupational therapists found that what most prevented a client-centred approach was therapists and patients having different goals. In a study with people with diabetes, Hunt et al. (1998) report that caregivers' goals were rooted in a clinical context, and failed treatment indicated uncooperativeness, while patients' goals were rooted in a life-world context in which options for adequate self-care were often lacking because of factors such as poverty or limited social power. Researchers working in areas other than diabetes have pointed out that personal goals related to patients' beliefs about illness and health derive from a lifeworld perspective (Hampson et al. 1990, Cohen et al. 1994, Allan 1998), while professional goals are greatly influenced by a biomedical scientific perspective learned in schools of nursing or medicine (Mizrahi 1986). Caregivers' attitudes towards patient education and learning have been studied by Holmström et al. (2003), who conclude that instead of focusing on patients' understanding and learning, caregivers mainly focus on giving information. This may be a consequence of their goals being different from those of patients. Our standpoint is that both perspectives, patient's and caregiver's, are important, but that healthcare professionals need to be aware of patients' goals, which may differ from medical goals. Furthermore, it is important to emphasize that ignorance of patients' goals may influence their satisfaction with clinical encounters. Patient-centredness in care is often defined as ‘entering the patient's world to see illness through the patient's eyes’ (McWhinney 1989, p. 25), including an understanding of the whole person and the individual experience of illness, finding common goals and enhancing a relationship based on care, sensitivity and empathy but also on self-awareness (Gerteis et al. 1993, Stewart 1995, Mead & Bower 2000).

The theme of patient autonomy and equality vs. patients' feeling forced into adaptation and submission is in line with research on compliance and empowerment, both of which have influenced current healthcare politics. Today, a changed view of patients' preferences, rights and power in care – and especially health promotion – is increasingly held, as evident from the empowerment research (see, e.g. Anderson & Funnell 2000). It seems that the change from health care characterized by authority and control exercised by the health professional to health care characterized by genuine interest in patients' self-management and emancipation has had an impact on patients' views of satisfactory encounters, since our interviewees preferred encounters based upon respect for their autonomy and equality instead of on compliance. From a patient perspective, Kralik et al. (1997) found that patients were positive when nurses asked and consulted them, but negative when they were not sufficiently informed. Reach (2003) describes therapeutic non-observance (i.e. non-compliance) as being related to the gap between two conceptions of health – the patient's individualistic beliefs and desires in which quality of life is viewed as predominant, and the healthcare provider's beliefs based on evidence-based medicine and consensus conferences. Brody (1992) points out that non-compliance from a caregiver perspective may be seen as defiance of irresponsible patients against authority, while Paterson (2001) argues that non-compliance from a patient' perspective is a conscious and well-grounded decision not to follow a caregiver's recommendations. This is a plausible interpretation in agreement with our findings that people with diabetes express satisfaction with those encounters they view as supporting their autonomy and equality.

In our interviews many patients talked about the importance of being valued as a person, not merely as a patient with a disease or as a case. These findings are in line with those of others. Kralik et al. (1997) found that detached nursing, when patients were treated as numbers, was a kind of depersonalization and promoted feelings of vulnerability and insecurity. Hellström (1999) highlighted how patients experience their reception and treatment in primary care and pointed to the benefits of viewing people with diseases as persons rather than patients. Thomas et al. (1995) likewise pointed to the importance of patients being treated as specific individuals and being given personal nursing care in order to increase their satisfaction. Winefield et al. (1996) highlighted the importance of person-centred care and defined it as ‘valuing people as individuals’ (p. 811). Callaghan and Williams (1994) also stressed the importance of person-centred care, which was described by the patients as valuing care in which nurses showed interest in patients and was well-informed about their situations. In Coyle's (1997) study, people's negative healthcare experiences were constructed in such a way as to illustrate how their perceptions of self and identity had been undermined by the experience. Coyle used terms such as ‘objectified’, ‘dehumanised’, ‘devalued’ and ‘disempowered’, which have many similarities with the way our participants described the unsatisfying encounters they had in health care.

The feeling that healthcare professionals are attentive and welcoming rather than ignorant is interpreted as satisfying. These findings correspond with those in work such as Duarte Climents and Aguirre Jaime (2003) questionnaire study of patient satisfaction with primary care nurses. These authors studied patient satisfaction among 4500 patients and found that they named kindness as the most important factor in healthcare consultations, followed by being listened to and trust. Our theme about feelings of being welcomed includes kindness, which was described as an important aspect of welcoming. Other research has pointed to factors such as healthcare professionals' attentiveness and taking time to listen, as well as demonstrating interest and commitment in the contact with patients, as being important for patient satisfaction (Gäfvert & Ek 1996, Lövgren et al. 1996). Kralik et al. (1997) found that nurses who were too busy and did not give patients enough attention resulted in perceptions of the nurses as insincere. Empathy and patience, as well as being given attention, has been seen to be related to patient satisfaction (Megivern et al. 1992). The more attention patients are given, the more satisfied they have been reported to be (Wolf et al. 1998).

Lastly, our findings show that patients' feelings of safety and confidence within the clinical encounter are connected to their satisfaction, while feelings of being unsafe and lack of confidence are connected to dissatisfaction. This finding is in line with that by authors such as Miller (2000), who points to the importance of receiving good advice from healthcare professionals. Other researchers have found that patient satisfaction is connected to patients' expectations that nurses will be knowledgeable and technically skilled (Armstrong 1987, Callaghan & Williams 1994). Other aspects related to safety and confidence, for instance healthcare professionals having specific knowledge about patients and giving good individualized treatment, have likewise been reported to increase patient satisfaction (Thomas et al. 1995). All findings from the cited reports were supported by our own.

Conclusion

Patient satisfaction with encounters in diabetes care has many similarities with patient- centredness in care, while dissatisfaction may be rooted in healthcare professionals' injurious actions and treatment of patients. Therefore, we believe that our findings, focusing on satisfaction as well as dissatisfaction with clinical encounters, have clinical relevance as they could be used as to improve consultation styles and evaluate patient satisfaction and dissatisfaction in clinical encounters in diabetes care. It is also important to raise healthcare professionals' levels of consciousness about patient satisfaction and dissatisfaction and their causes in order to improve the quality of care.

Acknowledgements

This study was supported by grants from the Swedish Diabetes Association, The Medical Faculty of Umeå University and the County Council of Västerbotten, Umeå, Sweden.

Author contributions

AH and BL were involved in the study conception and design; AH and ES performed the data collection; AH, ES and BL analysed the data; AH, HS and BL drafted the manuscript; HS and BL made critical revisions to the paper and supervised; AH obtained funding.

What is already known about this topic
* Type 2 diabetes is a chronic disease managed primarily by the affected individual.
* Several patient satisfaction surveys have focused on aspects such as privacy, cheerfulness and amenities rather than on how the care was delivered and what it aimed to achieve.
* A great deal of research has also focused on communication and various consultation styles, particularly within health promotion and diabetes care, but how these factors link with patient satisfaction has rarely been discussed.
What this paper adds
* Satisfying encounters were those in which patients experienced agreement, and felt autonomous, worthy, welcomed, safe and confident.
* Unsatisfying encounters, by contrast, were those in which patients experienced disagreement about goals, and felt forced into submission, worthless, ignored, unsafe and lacking in confidence.
* Patient satisfaction with encounters in diabetes care has many similarities with patient centredness in care, while dissatisfaction may be rooted in healthcare professionals' injurious actions and treatment of patients.
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Keywords: dissatisfaction; nursing; patient perspective; patient satisfaction; patient-centred care; type 2 diabetes



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