ORIGINAL ARTICLE

Quality of Care from a Patient Perspective

A Grounded Theory Study
Bodil Wilde, M MSc, RN’, Bengt Starrin, PhD’, Gerry Larsson, PhDa,
and Mayethel Larsson, PhD, RN”
T h e Centre for Public Health Research, The County Council of Varmland, Karlstad and
*Department of Geriatric and Long-Term Care Medicine, Vasa Hospital, University of Goteborg,
Goteborg, Sweden

Scand J Caring Sci 1993; 7: 113-120

The aim of the present study was to develop a theoretical understanding of quality of care from a patient perspective, using
a grounded theory approach. Thirty-five interviews were conducted with a sample of 20 adult hospitalized patients (mean age:
60 years) in a clinic for infectious diseases. Data were analysed according to the constant comparative method. A model was
formulated according to which quality of care can be understood in the light of two conditions, the resource structure of the
care organization and the patient’s preferences. The resource structure of the care organization consists of person-related and
physical- and administrative environmental qualities. The patient’s preferences have a rational and a human aspect. Within
this framework, patients’ perceptions of quality of care may be considered from four dimensions: the medical-technical
competence of the caregivers; the physical-technical conditions of the care organization; the degree of identity-orientation in
the attitudes and actions of the caregivers and the socio-cultural atmosphere of the care organization. The model is discussed
in relation to existing theories in the field.
Key words: Quality of care, grounded theory, patients’ perspective.

Submitted August 6, 1992

Accepted January 19, 1993

INTRODUCTION Studies of patients’ wishes in connection with care

Quality of care is a multidimensional concept which have usually not been directly focused on the concept
has been given different meanings in the literature. of quality of care. Rather, they have taken indirect
Broad definitions seem to focus on two major domains. questions, such as ‘what characterizes a good doctor
One of these mainly contains the substance of the or a good ward?’, as a point of departure. Examples
concept; for instance desirable characteristics of care, of early writings in this field are given by Cartwright
criteria, standards, and policy issues. The other domain (1967), Coser (1962), Freidson (1961), Hulka et al.
mainly contains evaluations of the outcome of care (197l), and Ware & Snyder (1975). The taxonomy of
(Donebedian 1966, 1989, Reerink 1990, Vuori 1992). patients’ wishes, derived from factor analysis by Ware
Patients’ views on what is important in connection & Snyder (1975), provides an illustration. Their model
with the care they receive may be seen as an aspect of is based on the following main dimensions: access,
quality, and patient satisfaction has increasingly come availability, continuity-convenience, and physician
to be used as an indicator of this quality (Bond & conduct and it is one of the most detailed ones as
Thomas 1992, Calnan 1988, Clearly & McNeal 1988, regards subdimensions. Based on an extensive review
Davis & Ware 1988, Morris 1989, Ware et al. 1983, of the literature, Donabedian (1980, 1989) formulated
Vuori 1991, WHO 1988, Taylor et al. 1991). Donabe- a model according to which patients’ wishes can be
dian (1980) considers that client satisfaction is a divided into three interrelated components: technical
judgement of the quality of care and not a part of the care, interpersonal care, and amenities. Several studies
definition of quality. It is. however, the best represen- of patients’ wishes, or patient satisfaction, have used
tation of certain components of quality, namely client definitions corresponding to these or to Ware’s and
expectations and valuations. Snyder’s ( 1975) dimensions ( Persson 1980).

113 Scund J Caring Sci

1 14 B. Wilde et al

Earlier studies of patients’ perception of quality Data collection

of care have been criticized on methodological
Data were collected by interviews (conducted by BW),
grounds (cf. Calnan 1988, Donabedian 1980, French
consisting of open-ended questions and individually
1981, Leino-Kilpi & Vuorenheimo 1992, Meterko et
adapted follow-up questions covering the following
al. 1990, Thompson 1986). In most studies, predefined
themes:
attributes have been used which respondents have
-Issues of importance with regard to the care the
been asked to choose between or rank ( Donabedian
patient received;
1980). Following this predefined approach, important
-What the patient perceived as positive or negative
aspects may be neglected. Thompson (1986) for in-
in connection with the care he or she received;
stance, claims that assessments of patient satisfaction
-Whether the patient felt anything was lacking dur-
often lack conceptual soundness and reflect aspects
ing the period of care;
considered important by researchers. These aspects
-Whether the patient wished to change anything
may or may not be of the same prominence to pa-
regarding his or her care.
tients. Leino-Kilpi & Vuorenheimo ( 1992) conclude
The interviews were conducted at the beginning of
that most studies of patient satisfaction only portray
the period of care (second or third day) (14 patients;
surface or superficial aspects of the phenomenon.
seven with unambiguous diagnosed and seven with
Therefore, more generative approaches are needed in
inconclusive), at the end of the period of care (the
order to develop the understanding of quality of care.
day on which the patient was discharged or the day
The aim of the present study was to develop a theoret-
before) (eleven patients; six with unambiguous diag-
ical understanding of quality of care from a patient
nosis and five with inconclusive) and after the period
perspective, using a grounded theory approach.
of care (1-2 months after discharge) (ten patients;
nine with unambiguous and one with inconclusive).
MATERIAL AND METHODS Altogether 35 interviews were conducted. Two pa-
tients were interviewed on all three occasions, eleven
Participants patients were interviewed twice, and seven patients
were interviewed on one occasion only. The reason for
The study was carried out at the Clinic for Infectious
interviewing some patients repeatedly was the desire
Diseases at the Central Hospital of Karlstad, Sweden,
to find a further possible source of variation. Inpa-
in 1989-1990. There are three wards in the clinic (49
tients were interviewed in their rooms if they were in
rooms-both single and double, 71 beds). Infected
single rooms, or in another room in the ward. Dis-
patients are isolated when necessary. Caring personnel
charged patients were mainly interviewed in the prin-
is organized in teams.
cipal author’s office and, in two cases, in their homes.
The selection of participants was guided by the
The interviews generally lasted about 60 to 90 min.
desire to find informants with a wide variety of experi-
The collection of data was concluded when a satura-
ences. Patients with infectious diseases were chosen
tion point was reached, the point at which the most
since we felt that they constitute a more heteroge-
recent interviews did not seem to make any substan-
neous group than patients in most other acute somatic
tial contribution to the model which had successively
departments (regarding for instance sex, age, educa-
been generated on the basis of earlier data.
tion. health status, and care in isolation or no care in
isolation). Patients with varying pathological pictures
Data unulysis
after 24 h at the department (unambiguous or incon-
clusive medical diagnoses) and with varying prognoses The interviews were taped and transcribed verbatim
for length of care-short (less than a wcek) or long and consecutively analysed according to the constant
(more than a week) --were selected. Meningitis, pneu- comparative method (Glaser & Strauss 1967, Starrin
monia. pyelonephritis. and wound infection were ex- et al. 1991). The first step was so-called open coding.
amples of unambiguous diagnoses, whilst fever of Data were examined line by line in order to identify
unknown origin was a typical inconclusive diagnosis. the patients’ descriptions of thought patterns, feelings,
Within each of the four categories. participants were and actions related to the themes mentioned in the
selected by lot. Informed consent was obtained from interviews. The codes derived were formulated in
the patients; on the day prior to the interview by the words used by the patients; this was an attempt to
head nurse and in direct connection with the interview maintain the semantics of the data. Codes were com-
by thc interviewer. The interviews were confidentially pared in order to verify their descriptive content and
treated. Three patients declined to participate for to confirm that they were grounded in the data.
health reasons. Twenty patients participated in the As a second step, the codes (about 900) were sorted
study. Ten were men and ten women and their aver- into categories ( n = 27). This was done by constant
age age was 60 years (ages ranged from 21 to 85). comparisons between categories. and between cate-
Scmitl J Curing Sci
 Quality of cure from a patient perspective 1 15

gories, codes, and interview protocols. Codes and me msoume stnicturt of the care orpnirnrion

categories were also analysed with respect to the Person-nlafed Qualifics relafed 10
qualifies [he physical and
patient selection criteria; i.e., comparisons were made odminisrrafiw care
ennromnr
between patients with varying length of care, with
unambiguous and inconclusive diagnoses, and of the
same patient at different times.
RorioruJiry
The third step consisted of fitting together the cate- Medical-technical Physical-technical
gories using the constant comparative method. It compelence conditions
ended up in a theoretical model which includes four me patient’s
dimensions and rests on two concepts or core variables. prtfertnces

Data collected at later stages in the study were used

to add to, elaborate and saturate codes, categories,
Identity-oriented SociwulNral
dimensions, and core variables. In practice, the steps approach atmosphere
of analysis were not strictly sequential. Rather, we
moved forward and backward constantly reexamining
data, codes, categories, dimensions, core variables,
and the whole model. Fig. 1. Model of quality of cure from u patient perspective.
In the following section the whole model will be
presented first, followed by a presentation of its di- and the socio-cultural atmosphere of the care organiza-
mensions and categories. The reason for this order of tion. A presentation of the model is given in Fig. 1.
presentation is the fact that the parts receive their
meaning when understood in relation to the whole Medical-technical competence
model.
When the patient’s desire for rational care is directed
RESULTS towards the person-related qualities of the care orga-
nization, he or she wishes those who provide the care
The emerging theory
to have a high level of ‘medical-technical competence’.
Patients’ perceptions of what constitutes quality of Rationality implies the availability of qualified per-
care are formed by their encounter with an existing sonnel who have the knowledge and proficiency to
care structure and by their system of norms, expecta- guarantee that the patient is given a relevant examina-
tions, and experiences. From the patients’ point of tion, that the correct diagnosis is made, and that the
view, quality of care can be regarded as a number of necessary measures are taken to effectively treat and
interrelated dimensions, which taken together form a alleviate the effects of the disease. Rational care
whole. The content of this whole can be understood in for the patient means that caregivers are available-
the light of two conditions (core variables) which that one can count on being received and treated by
could be labelled as ‘the resource structure of the care caregivers who are medically-technically competent.
organization’ and ‘the patient’s preferences’. The re- Medical-technical competence includes examination,
source structure is of two kinds: person-related and diagnosis, treatment, and symptom alleviation. As one
physical- and administrative environmental qualities. patient put it, ‘what is most important is to get cured
Person-related qualities refer to the caregivers (the when you are sick’. Another patient said: ‘The doctor
doctor, the nurse, the assistant nurse, etc). Physical must know what he should ask so you can find out
and administrative environmental qualities refer to what is wrong and get the right treatment’. Caregivers
infrastructural components of the care environment, should also carry out examinations, tests, and treat-
organizational rules, technical equipment, etc. ments in a correct, careful and conscientious manner.
The patient’s preferences are also of two kinds: on For instance, it was positively viewed that a wound be
one hand, they have a rational aspect in the sense that carefully bandaged. The following extract from an
the patient strives for some sort of order, a kind of interview with a middle-aged man with an ambiguous
FwxIictability and calculability in life (cf. Weber’s medical conditions summarizes a recurrent theme in
( 1922) ‘instrumental rationality’). On the other hand, the conversations:
they have a human aspect in that the patient expects Patient: I wish I had come here earlier, it feels so
his or her unique situation to be taken into account. good to know that there are a lot of people here
Patient’s perception of quality of care may be consid- with great knowledge. Back home you walk around
ered from four dimensions: the medical-technical with a lot of questions.
competence of the caregivers, the physical-technical Interviewer: Yes?
Patient: It’s a very good feeling to be here. You get
conditions of the care organization, the identity-orien- this feeling that they have a strategy, that they have
tation in the attitudes and actions of the caregivers, a certain pattern they skilfully work through.
Scund J Caring Sci
1 16 B. Wilde c ~ ra/

Physicd-techniccrl conditions are qualified caregivers with the knowledge and em-
When the patients’ desire for rational care is di- pathic skill to meet the patient as a unique person.
rected towards the physical- and administrative quali- The human aspect means that the caregiver shows an
ties of the care organization, it is a question of the interest in and a commitment to the patient as a
availability of a care organization providing the neces- person, i.e. in whom the unique person is, what he o r
sary ‘physical-technical conditions’. Rationality in this she wants and what his o r her needs are, and that the
respect means that the patient can count on the caregiver reveals his or her own feelings and sympathy
hospital, the ward, and the room to provide the for the patient. Humanity implies a symmetrical rela-
necessary physical-technical resources for the cure and tionship between patient and caregiver which is char-
care he or she is in need of. The rational aspect lies in acterized by mutual understanding, respect, trust,
the fact that the environment is clean, comfortable. honesty, and collaboration
and safe, and that good sanitary conditions, food An identity-oriented approach on the part of the
and drink are available as well as advanced medical- caregiver includes showing an interest in and a com-
technical equipment. mitment to the patient’s situation and treating him o r
Physical-technical conditions include the availabil- her with respect. Patients are often worried about
ity of medical-technical equipment; e.g., laboratories causing too much trouble, about being considered
and x-ray equipment necessary for conducting exami- ‘difficult’. If the caregivers just ‘look-in’, patients feel
nations. The same is true of equipment necessary for that the caregiver has time for them as persons and
treatment and care, such as walking aids, drugs, not just for the job that has to be done. Patients
probes, etc. should be met seriously and not treated as objects.
The physical environment should be clean and tidy One does not want to be ‘just anybody’, ‘one of the
and beds and other furniture should be comfortable. rest’, ‘one in a crowd, ‘a package’, ‘a number’, o r ‘the
The following extract from an interview with an old leg in room X’, as some of the patients put it.
woman who had been given an antidecubitus mattress The following extract provides an illustration to
provides an illustration. how, in connection with having a wound dressed, a
Patient: I’m comfortable now. I have one of those mat- 40-year-old man experienced that on one occasion he
tresses. . . I’ve had a bit of pain in the hip for the last few was met with respect and another more as an object.
years. so it’s a bit difficult to lie and not be able to sleep.
Patient: Some are so very human and I know when they’re
The care environment should provide access to dressing my wound, people are so different, some only
communication means such as radio, television, and think about getting it done in three seconds. Some think
telephone. A library and post office should be accessible. about washing and cleaning the wound so it doesn’t get
The sanitary conditions in the ward are important worse. Some don’t care if it gets worse. Just as long as
they can get away, get it done. They just pull off the old
components of the physical-technical conditions. It is dressing and throw it away.
vital that hygiene articles and a change of clothes are Interviewer: What do you feel like then?
available. Patients should not have to wait until a Patient: You feel rather cheap, in fact, it makes you feel
caregiver comes into the room or have to ring and ask like a package.
for a change of clothes.
The identity-oriented approach also includes an
Nutrition is another aspect of the physical-technical
approachable personal style on part of the caregiver.
conditions. The care organization should provide pa-
He or she should be ‘warm’, ‘nice’, ‘cheerful’, ‘pleas-
tients with some choice regarding different dishes.
ant’, ‘kind’, or ‘decent’ rather than ‘cold’, ‘surly’,
When a patient is unable to feed him/herself, other
‘harsh’, ‘sharp’, or ‘stern’. Identity-oriented thoughts
nutrition methods should be available, e.g. intra-
and actions also imply the caregivers showing sympa-
venous feeding (drip). ‘I get drip feeding, it is nice you
thy when patients are suffering, e.g. in pain. Similarly,
can be fed like that when you can’t manage to eat
caregivers should reveal their own feelings to the
yourself’, as one patient put it.
patient, e.g. happiness if a certain form of treatment.
Physical-technical conditions also include a safe
had been successful.
physical environment. Cupboards for personal be-
Honesty and sincerity are further characteristics G f
longings and doors that can be locked are essential.
an identity-oriented approach. Caregivers who wer:
Another vital piece of equipment is a working bell-
honest and sincere in response requests, who ‘told th.:
push so that one can call for help if necessary.
truth’, or ‘gave honest answers’ were trusted and
appreciated by the patients in the present sample.
Identity-oriented upproach
Caregivers should also show trustfulness, so that pa-
Patient’s desire for care with a human face in relation tients feel that the caregivers trust and believe in them
to the caregivers is a question of an ‘identity-oriented and that they can be open and sincere; that they ‘dare’
approach’. Humanity in care presupposes that there to ask questions and make requests as someone put it.
Scund J Curing Sci
 Qualiry of care from a patient perspective 1 17

Another aspect of an identity-oriented approach is Another feature of the identity-oriented approach

understanding in the sense that the caregivers put concerns collaboration. Caregivers should allow and
themselves in the patients’ place and have empathy. It support patients to participate in the care process
is a matter of understanding the patients’ experiences when they wish. Some of the patients said: ‘I want to
and the reasons for them. take part in the discussions on my body, it is me who
Understanding also involves patients’ comprehen- is involved’, ‘it feels so nice, it’s just like being part of
sion of what has happened, what is happening, and the team, I get information and they ask what I think’
what is going to happen; e.g. what treatment is going and ‘I think they have to ask me, it’s a must. The
to be applied and what the expected results are doctor might not think it’s so important, but it is to
Caregivers should inform patients in an intelligible me’. Some patients may think it is better that the
manner providing them with opportunities to ‘ask caregiver, ‘the expert’, decides what is best for them.
questions’ and ‘discuss the information’ in a dialogue. But at the same time, as they leave the decision to the
Information about examinations, treatments, etc., caregiver, they may want collaboration in the sense of
particularly negative information, should not be given being informed of what is happening and of being
‘too suddenly’, ‘without prior warning’, ‘like a bolt able to explain what they feel.
from the blue’. The following extract from an inter-
view with an elderly woman whose diagnosis was Socio -cultural atmosphere
inconclusive, provides an illustration of the impor-
Patients’ desire for a humane physical- and adminis-
tance of being prepared.
trative care environment implies demands in what
Patient: . . . it was like a real surprise to get it. They had could be labelled the ‘socio-cultural atmosphere’ of
taken two ECGs with a day in between and I didn’t react the care environment. A humane environment is one
to their coming and wanting to take new tests like that. I
didn’t think about it, for they could have said after the which as much as possible resembles a home rather
first one that we have seen that it’s not so good. There’s than an institution, one where the wishes and needs of
something not right with your heart, so we’re going to do the patients have priority over fixed routines. It is an
it again, we’ll see, look at it more closely. But nobody said environment where the patient has the opportunity
anything. for self-chosen seclusion and/or self-chosen socializing
Interviewer: What difference would it have made?
Patient: I would have been prepared in another way, whenever he or she wishes. Furthermore, it is an
prepared for the worst. Now there comes this doctor from environment with a convivial atmosphere.
another clinic and says you’ve had a heart attack. The care organization should provide patients with
Interviewer: Did you have any questions to put to the the opportunity for socializing; to be able to meet
doctor?
Patient: Yes, but when it comes so suddenly, everything relatives, friends, caregivers, and/or fellow patients
goes blank, you don’t have any questions for all that a t times they themselves wish. A related point is
matters is what’s happened to me. the opportunity for seclusion when desired. Patients
Interviewer: Did the questions come later? should have access to an undisturbed environment
Patient: Yes, after, yes just so, when, how and where it where they can have ‘peace and quiet’, and not be
happened, yes.
Interviewer: Did you talk to the staff about it later? ‘disturbed’ but can rest and sleep. Patients who share
Patient: No, I don’t think so, no. Now, the worst part is a room should have access to an undisturbed environ-
not knowing who is in charge of it, of me, so to say. . . ment where they can have private conversations with
This illustrates another aspect of an identity-oriented the caregiver. We illustrate this with an interview
approach; informing the patient who is responsible for extract with a woman in her seventies.
his or her care. Patients should know who ‘is in charge Patient: . . . you might perhaps want to say something to
of them’. They should also be given opportunities to the doctor but no, I think, it’s not nice having so many
‘get t o know’ the person who is to look after them. listening, so I don’t bother. . . If we could go in and sit
somewhere and talk a little more confidentially.. .
In the interviews patients said it was ‘difficult meeting
new caregivers all the time’, ‘having to explain over A further point of the socio-cultural atmosphere is
a n d over again’. Many of them did not want to tell that patients should be able to use their own clothes
everybody everything. They were also afraid that they and have personal belongings in the room if they
might forget something that was essential for their care. wish; it should be a home-like environment.
An identity-oriented caregiver attempts to be on the Another aspect here concerns routines. Caregivers
same level as the patient. Caregivers should ‘not be should not be ‘tied to routines’; they should listen and
above them’ and ‘not be military-like’. For instance, help the patient in the way that he or she wants. This
in this study many patients claimed that they appreci- might, for instance, be a matter of being able to
ated if the caregiver sat down while talking to them, decide when one wants to take a shower. As one
rather than stood at the foot of the bed; it was even patient put it: ‘it’s so nice here, I can take a shower
better if both could sit down and talk. every day. Where I was before you showered on
Scand J Caring Sci
118 B. Wilde et al.

certain days’. On the other hand, strict adherence previous studies we have not found any explicit at-
to routines is appreciated regarding the handling of tempts to theoretically relate dimensions into this kind
patient’s records. of conceptual framework. This may be a useful pro-
A further point is the general atmosphere in cess since conceptual abstraction enables us to relate
the ward; there should be a positive ‘atmosphere’ or the model more closely to existing theory of a more
‘climate’, the caregivers should get on well together. general nature (Glaser 1978). An example of this is
Relatives, friends, and fellow-patients should be that the combination of medical-technical competence
treated with dignity. and physical-technical conditions resembles what is
often referred to as the medical model of care in the
literature. The combination of an identity-oriented
DISCUSSION
approach and a social-cultural atmosphere, is like-
The suggested model includes many of the aspects wise similar to the theorizing on so-called psychoso-
previously mentioned in the literature on quality of matic care models (Christie & Mellet 1986). Further,
care, (cf. Donabedian 1980, 1989; Ware & Snyder the combination of the dimensions medical-technical
1975). Regarding the dimension ‘medical-technical competence and an identity-oriented approach con-
competence’. all categories can be found in the litera- stitutes what could be labelled as professionalism.
ture. In previous models and patient satisfaction as- This involves an extension of the concept ‘profession-
sessment tools, these aspects have frequently been alism’ in health care settings in comparison with
labelled examinations, medications, professional com- most authors who tend to emphasize the instrumental
petence, technical competence, technical-professional competence (see e.g. Starrin 1981).
and technical skills (see e.g. Brody et al. 1989, von In order to exemplify the suggested interdependence
Essen & Sjoden 1991, Hulka et al. 1971, Risser 1975. of the dimensions, it may be observed that many
Ware & Snyder 1975). patients related the medical-technical competence of
The dimension ‘physical-technical conditions’, is the personnel to their emotional well-being. Similarly,
also described in the literature; Donabedian (1980) patients often pointed to what we have termed the
talks about the amenities for instance. Aspects related identity-oriented approach of the caregivers as a sig-
to this area of care have often been labelled accessibil- nificant factor in motivating them to follow medical
ity, bed quality, cleanliness of the ward, food services, prescriptions (cf. Donabedian 1988).
medications, and toilet and washing facilities (see e.g. When one considers the data underpinning our
Brody et al. 1989. Henderson 1960, Nightingale 1859, model, one finds support for the idea of team-work,
Ware & Snyder 1975). so-called participatory care, where the patient, if he or
The dimension ‘identity-oriented approach’, is also she wishes, is part of the team (cf. Larsson, Starrin &
well covered in existing models. Donabedian (1980) Wilde 1991). Similar ideas have been suggested by a
labels these aspects interpersonal care. All categories number of nursing theorists (see e.g. Fawcett 1987)
within this dimension of care have been noted previ- but these models are often. but not always, limited
ously under headings such as affective care, attitudes, to the role of the nurse (Athlin 1992, Bloch 1975,
communication, continuity, control over treatment Henderson 1978, 1982, van Mannen 1981).
decisions, empathy, information, interaction, personal The study does not permit any conclusions regarding
qualities. social support, and trust (see e.g. Hinshaw the relative importance of the dimensions. One dimen-
& Atwood 1981, Israel 1962, Marran et al. 1979, sion may be of prime importance in one care context.
Risser 1975). while another may dominate in another. Person-related
A difference between the proposed model and previ- conditions which could be assumed to affect the impor-
ous writings may be that the dimension ‘socio-cultural tance of the dimensions include age, education, per-
atmosphere’ is not emphasized to a similar extent in sonality, sex, and state of health (see e.g. Davis & Ware
existing models. However, some of these aspects are 1988). Situation-related conditions which may be im-
mentioned in the literature. Phillips et al. (1990) cover portant are a given illness’ objective degree of pre-L
some of these qualities under the heading ‘environ- dictability-ambiguity and the actual length of the car,e
mental’, and some parts of Donabedian’s (1980) time (see e.g. Lazarus & Folkrnan 1984). Empirical
amenity dimension. seem to cover socio-cultural as- studies in different care settings are needed to evaluate
pects. Astedt-Kurti & Haggmark-Laitila ( 1991) also these aspects.
report on the importance which patients attribute to a We d o not claim to have captured all the different
homely hospital environment. components of patients’ views on quality of care. W:
In the suggested model, the four dimensions of care have been limited to use the components revealed by
can be understood in the light of the interaction our data obtained from a selected group of patients.
between two core variables; the patients’ preferences Further studies in a variety of patient groups are
and the resource structure of the care system. In needed to evaluate and develop the presented model.
Scand J Caring Sci
 Quality of care from a patient perspective 119

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