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The impact of occupational stereotypes in human-centered service systems

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Purpose The purpose of this paper is to explore the impact that occupational stereotypes held by customers have on value co-creation processes in human-centered service systems (HCSSs) like hospitals. Specifically, by exploring if and how customers’ (i.e. patients’) stereotypes toward frontline employees (e.g. nurses) affect their satisfaction as co-creators of value, this study responds to current service research priorities attempting to understand value co-creation in collaborative contexts like healthcare, and addresses calls to investigate the changing role of health care customers therein. Design/methodology/approach A field study was conducted in the context of German hospitals, which provides unique empirical evidence into the relationship between patients’ stereotypes toward healthcare professionals and their satisfaction with health services as well as the mediating mechanisms through which such stereotypes affect patient satisfaction. Findings Negative (positive) stereotypes patients hold toward healthcare occupations decrease (increase) their satisfaction and are associated with perceptions of reduced (improved) patient orientation and patient participation in co-creation. However, only perceived patient orientation partially mediates the link between occupational stereotypes and patient satisfaction. Originality/value This study develops and tests new hypotheses related to occupational stereotyping in complex HCSSs, and extends previous research on stereotypes in service by exploring the previously unknown mediating mechanisms through which these impact value co-creation processes overall. It furthermore provides important guidance for future research about stereotyping in general, and its impact on value co-creation and HCSS, in particular.
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Journal of Service Management
The impact of occupational stereotypes in human-centered service systems
Antje Sarah Julia Huetten, David Antons, Christoph F. Breidbach, Erk P. Piening, Torsten Oliver
Salge,
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Antje Sarah Julia Huetten, David Antons, Christoph F. Breidbach, Erk P. Piening, Torsten Oliver
Salge, (2019) "The impact of occupational stereotypes in human-centered service systems", Journal
of Service Management, Vol. 30 Issue: 1, pp.132-155, https://doi.org/10.1108/JOSM-12-2016-0324
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The impact of occupational
stereotypes in human-centered
service systems
Antje Sarah Julia Huetten and David Antons
Institute for Technology and Innovation Management, RWTH Aachen University,
Aachen, Germany
Christoph F. Breidbach
The University of Melbourne, Parkville, Australia
Erk P. Piening
Johannes Gutenberg University Mainz, Mainz, Germany, and
Torsten Oliver Salge
Institute for Technology and Innovation Management, RWTH Aachen University,
Aachen, Germany
Abstract
Purpose The purpose of this paper is to explore the impact that occupational stereotypes held by
customers have on value co-creation processes in human-centered service systems (HCSSs) like hospitals.
Specifically, by exploring if and how customers(i.e. patients) stereotypes toward frontline employees
(e.g. nurses) affect their satisfaction as co-creators of value, this study responds to current service research
priorities attempting to understand value co-creation in collaborative contexts like healthcare, and addresses
calls to investigate the changing role of health care customers therein.
Design/methodology/approach A field study was conducted in the context of German hospitals, which
provides unique empirical evidence into the relationship between patientsstereotypes toward healthcare
professionals and their satisfaction with health services as well as the mediating mechanisms through which
such stereotypes affect patient satisfaction.
Findings Negative (positive) stereotypes patients hold toward healthcare occupations decrease (increase)
their satisfaction and are associated with perceptions of reduced (improved) patient orientation and patient
participation in co-creation. However, only perceived patient orientation partially mediates the link between
occupational stereotypes and patient satisfaction.
Originality/value This study develops and tests new hypotheses related to occupational stereotyping in
complex HCSSs, and extends previous research on stereotypes in service by exploring the previously
unknown mediating mechanisms through which these impact value co-creation processes overall. It
furthermore provides important guidance for future research about stereotyping in general, and its impact on
value co-creation and HCSS, in particular.
Keywords Stereotypes, Health services, Service dominant logic, Customer satisfaction, Value co-creation
Paper type Research paper
Introduction
On October 12, 1980, Ruth S. lost her husband after he was admitted to a hospital and did
not wake up from what doctors had initially described as minor routine surgery.
Ever since that tragic moment, Ruth questioned both the competence and the motives of
medical doctors and other clinical professionals. In fact, for the rest of her life,
Ruth held strong negative beliefs against all healthcare professionals, was highly
skeptical of medical advice given to her, and generally hesitated to participate in any
medical treatment.
The introductory example of Ruth is by no means an isolated case. Berry and Bendapudi
2007) highlighted that it is difficult to imagine a service where customers are more at risk
than [] healthcare(p. 116). Healthcare takes place in human-centered service systems
Journal of Service Management
Vol. 30 No. 1, 2019
pp. 132-155
© Emerald Publishing Limited
1757-5818
DOI 10.1108/JOSM-12-2016-0324
Received 14 December 2016
Revised 23 September 2017
14 June 2018
17 August 2018
1 October 2018
Accepted 26 November 2018
The current issue and full text archive of this journal is available on Emerald Insight at:
www.emeraldinsight.com/1757-5818.htm
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(HCSS), which are complex configurations of people, information, organizations and
technologies, dominated by human behavior, human cognition [and] human emotions
(Maglio et al., 2015, p. 2). When faced with ill-health, alternative treatment options, as well as
information asymmetries or the need to coordinate interactions with multiple medical
professionals, patients commonly experience cognitive overload (Epstein and Street, 2011),
as well as stress and anxiety (McColl-Kennedy, Hogan, Witell and Snyder, 2017;
McColl-Kennedy, Danaher, Gallan, Orsingher, Lervik-Olsen and Verma, 2017;
McColl-Kennedy, Snyder, Elg, Witell, Helkkula, Hogan and Anderson, 2017). As was the
case of Ruth, these factors place an additional strain on the already limited human
information processing abilities and bounded rationality (e.g. Simon, 1996). Hilton and von
Hippel (1996) showed that human actors like Ruth reduce complexity and attempt to process
information more efficiently in these situations by applying stereotypes to their
environment (Hamilton and Trolier, 1986; Oakes et al., 1994). Stereotypes are generalized
impressions about the characteristics (i.e. appearance, beliefs and skills) and behaviors of
socially constructed groups of people (e.g. gender, age and occupational groups) (Allport,
1954; Hilton and von Hippel, 1996). Specifically, stereotypes geared toward specific
professional groups such as physicians and other caregivers (here referred to as
occupational stereotypes) help individuals like Ruth to simplify their interactions with
clinical professionals and thereby reduce the complexity of HCSSs, especially when
information asymmetries or cognitive overload are prevalent.
It is against this backdrop that the present work seeks to explore how patients
stereotypes toward healthcare occupations relate to patientswillingness to co-create
health service processes, and ultimately affect patientssatisfaction with the service
experienced. This investigation is highly relevant for service theory and practice because
stereotyping is common in contexts ranging from healthcare (Bogart et al., 2004), to
nonprofits (Aaker et al., 2010) or retail (Babin et al., 1995), and is used by service customers
and frontline employees alike (Mai and Hoffmann, 2011). In this regard, Vargo and Lusch
(2016, p. 11) recently suggested that institutions, i.e. humanly devised rules, norms, and
beliefsplay a key role in orchestrating service processes because they enable and
constrain action, and make social life at least somewhat predictable and meaningful
(Vargo and Lusch, 2016, p. 11). Stereotyping can be seen as such an institution that shapes
actorscognition, communication and judgment. However, despite the importance of
stereotyping for understanding value co-creation, more generally, and value co-creation
processes in HCSSs, such as hospitals more specifically, theoretical and empirical insights
into stereotyping are limited. In fact, research on stereotypes to date is fragmented across
multiple disciplines ranging from social psychology (Schneider, 2005), to marketing
(Homburg et al., 2011) or medical research (Bogart, 2001), with contributions to date
lacking a strong unifying theoretical foundation. Furthermore, while some studies provide
insights into the attitudinal (e.g. patient satisfaction, Bogart et al., 2004) and behavioral
(e.g. adherence to treatment guidelines, Ditto et al., 1995) consequences of stereotyping in
service settings, much less is known about the mechanisms through which stereotypes
affect these attitudes and behaviors.
This study addresses critical gaps in knowledge pertaining to stereotyping and value
co-creation by exploring the important and previously uninvestigated question of how
occupational stereotyping affects value co-creation processes in HCSSs. It provides three
meaningful contributions to service research and practice. First, this study builds on S-D
logics latest Foundational Premise (FP) 11 that value co-creation is coordinated through
actor-generated institutions and practices(Vargo and Lusch 2016, p. 18), to conceptualize
occupational stereotyping as an actor-generated institutional practice, and to develop and
test hypotheses related to its impact on value co-creation in complex HCSSs. As such, this
study addresses a theoretical gap in service research, which long assumed customers to be
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both able and willing to act as active resource integrators and co-creators of value (Vargo
and Lusch, 2008). Only recently has this assumption been challenged, with Seiders et al.
(2015) explaining that customers are often unwilling to do so, while Santos and Spring (2015)
and Breidbach and Maglio (2016) finding that customers can actively disengage from
resource integration as a precondition to value co-creation processes. The new emerging
understanding of customers portrays these more realistically as boundedly rational actors,
who apply institutional practices (i.e. stereotyping) that can ultimately limit their ability or
willingness to actively engage in value co-creation (Vargo and Lusch, 2016). By exploring
stereotyping as one example for such an institutionalized practice that is driven by bounded
rationality, this study provides new insights related to value co-creation in complex HCSSs.
It thereby directly responds to Ostrom et al.s (2015) service research priority of
understanding value creation(p. 138), in multi-actor, network and collaborative contexts
(p. 138) like healthcare.
Second, this research provides an empirical contribution to the service literature through
a field study that was conducted in the German hospital context and explores the
relationship between patientsstereotypes toward healthcare professionals and value
co-creation. Specifically, it investigates the link between stereotyping and customers
satisfaction with healthcare, shedding new light on perceived patient orientation and patient
participation in co-creation as previously unexplored mediating mechanisms of this
relationship. This present work, therefore, adds to the discourse on health service research
more generally (e.g. Danaher and Gallan, 2016), and provides a much-needed empirical
response to recent calls for service research to investigate the role of customers in health
service, more specifically (McColl-Kennedy et al., 2012; McColl-Kennedy, Hogan, Witell and
Snyder, 2017; McColl-Kennedy, Danaher, Gallan, Orsingher, Lervik-Olsen and Verma, 2017;
McColl-Kennedy, Snyder, Elg, Witell, Helkkula, Hogan and Anderson, 2017).
Third, this work provides important guidance for future service research aiming to
advance knowledge about actor-generated institutions like stereotyping in general, and its
impact on how value co-creation processes are coordinated, in particular. It is also of
considerable managerial relevance, as it informs current trajectories in health service
that aim to shift from asymmetric and physician-dominated interactions to more
customer-centric service where patients are active co-creators of value (McColl-Kennedy,
Hogan, Witell and Snyder, 2017; McColl-Kennedy, Danaher, Gallan, Orsingher,
Lervik-Olsen and Verma, 2017; McColl-Kennedy, Snyder, Elg, Witell, Helkkula, Hogan
and Anderson, 2017). Specifically, this study provides important managerial guidelines
that support health service practitioners attempting to re-align their HCSS based on the
novel understanding of stereotyping in a quest to achieve human-centeredness.
This study can thereby help to improve HCSSs like hospitals, which are often designed
with procedural effectiveness and efficiency, rather than personal comfort or human
well-being in mind (Breidbach et al., 2016).
This manuscript is structured as follows: first, existing knowledge on stereotyping in
service settings is synthesized. Second, hypotheses on the effects of stereotypes on
healthcare outcomes and processes are developed, and the empirical findings are presented,
before being discussed in the broader context of the extant literature. Finally, this
manuscript delineates future research opportunities and managerial implications.
Background and hypotheses
Stereotypes in human-centered service systems
Stereotypes have been examined in disciplines like social psychology (e.g. Schneider, 2005),
marketing (e.g. Homburg et al., 2011) or medical research (e.g. Bogart, 2001). Despite these
different disciplinary foci, there is an overall consensus regarding the basic function,
processes and consequences of stereotyping. For one, as a human practice, Hilton and
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von Hippel (1996) argue that stereotypes involve beliefs about the characteristics,
attributes, and behaviors of members of certain groups(p. 240). The primary function of
stereotyping, therefore, lies in reducing complexity, and saving individualslimited
cognitive resources (Macrae et al., 1994; Macrae and Bodenhausen, 2000). Indeed, by
categorizing others based on their age, gender, ethnic, occupational or other superficial
attributes, and assigning perceived group characteristics (e.g. laziness, dishonesty or
arrogance) to them, human actors apply stereotypes with the intention to reduce the
inherent complexity in their environment (Fiske and Neuberg, 1990; Posthuma and
Campion, 2009; Schneider, 2005). Further explanations for the tendency to stereotype can be
found in social identity theory (Ashforth and Mael, 1989; Tajfel and Turner, 1979), which
postulates that categorization processes like those underpinning stereotyping are associated
with the depersonalization of others. However, this can, in turn, lead to inaccurate and
distorted (often negative) opinions, unfair treatment of people, and wrong decisions
(Posthuma and Campion, 2009).
Stereotyping, both in positive and negative ways, occurs predominantly in complex
environments where information asymmetries are prevalent, and which are designed
with procedural effectiveness and efficiency, rather than human well-being in mind
(e.g. Breidbach et al., 2016). One example for such an environment is HCSSs set in the
context of healthcare. Specifically, patients in HCSS experience interactions with multiple
actors, including medical professionals, support staff or family members (e.g. McColl-
Kennedy et al., 2012). In addition, information asymmetries between patients and medical
staff (e.g. Surprenant and Solomon, 1987), physically and emotionally strained employees
(e.g. Berry and Bendapudi, 2007), as well as patientsown ill-health, can put substantial
cognitive strain on patients (e.g. Breidbach et al., 2016), and result in anxiety and stress
(e.g. McColl-Kennedy, Hogan, Witell and Snyder, 2017; McColl-Kennedy, Danaher, Gallan,
Orsingher, Lervik-Olsen and Verma, 2017; McColl-Kennedy, Snyder, Elg, Witell, Helkkula,
Hogan and Anderson, 2017). These reactions do, in turn, affect value co-creation processes
(McColl-Kennedy, Hogan, Witell and Snyder, 2017; McColl-Kennedy, Danaher, Gallan,
Orsingher, Lervik-Olsen and Verma, 2017; McColl-Kennedy, Snyder, Elg, Witell, Helkkula,
Hogan and Anderson, 2017)[1]. Vargo and Lusch (2016), therefore, highlighted the need to
understand how value co-creation processes are coordinated in situations where a
customers (i.e. patients) cognitive abilities may be constrained. Vargo and Lusch (2016)
further postulate that the coordination of value co-creation takes place through
actor-generated institutions, which are routinized social norms, practices or activities that
provide a shortcut to cognition, communication, and judgment(Vargo and Lusch, 2016,
p. 11). Stereotyping thereby represents an actor-generated institution that is defined within
this study as an individual actors subjective beliefs about the personal characteristics
(i.e. appearance, beliefs) and attributes (i.e. gender, race) of others and their roles in socially
constructed groups, and that are applied to reduce complexity especially when ambiguities,
information asymmetries or cognitive overload are prevalent.
To date, there is only a small but growing body of work on how stereotypes affect service
interactions (e.g. Luoh and Tsaur, 2011). Much of this work focuses on stereotypes that
customers hold toward frontline employees, which complements the broader literature on
customer expectations that addresses the role of customers pre-established expectations
regarding service quality more generally (e.g. Zeithaml et al., 1993). Conceptually,
stereotypes can be seen as antecedents to expectations in service interactions. Especially,
when customers have insufficient or ambiguous information, they have been found to make
inferences about the attitudes, capabilities and performance of frontline service employees
by drawing on easily observable cues, including a persons physical attractiveness, age or
gender (Hekman et al., 2010; Luoh and Tsaur, 2009, 2011). The literature to date has devoted
particular attention to gender, age and occupational role stereotypes, with social role theory
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highlighting the importance of socially shared beliefs regarding the characteristics,
attitudes and behaviors of people occupying certain positions or being member of a certain
social group (Eagly and Karau, 2002; Koenig and Eagly, 2014). As such, the extent to which
individuals comply with their expected social roles influences the process and outcomes of
social interactions such as service encounters (Solomon et al., 1985). For example,
counterstereotypical service providers (e.g. in terms of occupational gender stereotypes) are
evaluated differently, though not necessarily worse, from a stereotypical service provider
(Iacobucci and Ostrom, 1993; Matta and Folkes, 2005).
Linking occupational stereotypes and patient outcomes
This study focuses on stereotypes in HCSSs like healthcare and, more specifically, on the
stereotypes hospital inpatients hold toward physicians, nurses and other caregivers
(e.g. therapeutic staff )[2]. These occupational stereotypes can be either positive or negative.
For example, positive stereotypical beliefs about physicians may include intelligent,
educated and hard-working, while nurses may be perceived as caring, helpful and kind
(Bogart et al., 2004). However, when faced with potentially life-threatening situation and
information asymmetries, some patients may even hold unrealistically positive stereotypes,
viewing physicians as demigods who are omniscient (Hall et al., 2001). In contrast, examples
of negative occupational stereotypes may include that physicians tend to be rude, arrogant
and do not have time to take care of patients. While empirical evidence suggests that
negative stereotypes toward caregivers (i.e. physicians) are less prevalent than positive ones
(Bogart et al., 2004), such stereotypes can have far-reaching consequences. In particular,
they are likely to negatively influence patientsevaluations of healthcare providers and their
value propositions, which ultimately may have detrimental effects on the perceived
performance of HCSS overall. For instance, negative stereotypes toward physicians have
been found to reduce the likelihood that patients seek care or are willing to adhere to
treatment guidelines (Bogart et al., 2004; Ditto et al., 1995). However, despite these
documented effects of stereotyping, the impact that stereotyping has on value co-creation
processes in healthcare and other service sectors as well remains incompletely
understood. Previous research focused predominantly on physicians, thereby neglecting
stereotypes toward other employees such as nurses (e.g. Bogart et al., 2004), and has also
been surprisingly silent about how stereotypes actually take effect.
The present study addresses this gap in knowledge by examining two mediating
mechanisms in the stereotypes-patient satisfaction relationship, namely, patient orientation
of the healthcare professional, and patientsparticipation in the co-creation of their health
service. While the former mediator reflects patientsbeliefs about the extent to which
caregivers seek to address their needs and preferences, and is thereby part of a service
providers value proposition (Vargo and Lusch, 2016), the latter captures patientsperceived
involvement in the care process as active co-creators of value. Figure 1 depicts the
relationships examined in this study.
First, a direct relationship between patient stereotypes toward caregivers and patient
satisfaction can be expected. Patient satisfaction, that is, patientssubjective evaluation of
the experience with their health service, is a particularly relevant and widely studied
outcome of hospital services (e.g. Baluch et al., 2013; Hausman, 2004; Hudak et al., 2003).
Evidence suggests that satisfied patients are, for example, more likely to comply with
medical recommendations, spread positive word-of-mouth, show more loyalty to hospitals,
and ultimately contribute to increased hospital profitability (Choi et al., 2004; Nelson et al.,
1992). In light of these positive health and financial effects, considerable attention has been
devoted to examining the antecedents of patient satisfaction. Various sociodemographic
factors (e.g. patient age, Hall and Dornan, 1990), patientsperceptions of physician and nurse
behavior (e.g. communication, emotional support and patient orientation), as well as the
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overall service quality (e.g. Choi et al., 2004), and clinical outcomes (e.g. patients health
condition after the treatment, Kane et al., 1997) are examples of predictors of patient
satisfaction discussed in the literature.
Patientsexpectations are widely believed to play a key role for predicting their
satisfaction with healthcare services, with unmet expectations regarding the quality of
healthcare being an important reason for dissatisfaction ( Jackspm et al., 2001; Thompson
and Sunol, 1995). In this regard, it is important to distinguish stereotypes from the related,
yet broader construct of customer expectations. While customer expectations serve as a
well-established construct against which the performance of service processes are judged
(Zeithaml et al., 1993), stereotypes encompass more stable beliefs individual customers hold
about the attributes of members of social groups; in this case, service frontline employees
(Hilton and von Hippel, 1996). It is important to acknowledge that patientsexpectations
result not only from their prior healthcare experiences or word-of-mouth, but are also
influenced by the stereotypes they hold. Accordingly, patients may request to be treated by
senior physicians only, given the stereotypical assumption that the level of seniority is
associated with greater competence. Stereotypes toward caregivers, in contrast, are not
necessarily related to patientsprior healthcare experiences, but may emerge in response to
social roles and societal perceptions. For example, there is evidence to suggest that fictional
portrayals in TV series (e.g. Greys Anatomy) shape patientsperceptions of the attributes
and behaviors of physicians and nurses (Quick, 2009). Therefore, occupational stereotypes
can directly and indirectly influence service processes and outcomes directly by leading to
biased evaluations of the service experience and indirectly as antecedents of expectations
regarding frontline employeesappearance and behaviors. However, only very few studies
have explicitly examined the influence of stereotypes on patient satisfaction, but focused
mainly on gender and ethnical stereotypes toward physicians. For instance, as a
consequence of implicit gender and racial stereotypes, nonwhite and female physicians have
been found to receive lower patient satisfaction evaluations (Hekman et al., 2010).
Furthermore, LaVeist and Nuru-Jeter (2002) observed that patients with the same ethnic
background as their physicians reported greater satisfaction compared to those with a
dissimilar ethnic background.
This study builds upon and complements previous research by examining stereotypes
toward caregivers in general, including nurses and therapeutic staff, rather than exploring
stereotypes held solely toward physicians, as done by Bogart and colleagues (2004).
Specifically, this study asks how occupational stereotypes influence patient satisfaction?
Patientsevaluations of health services critically rely on their perceptions of caregivers (e.g.
appearance, skills and kindness) and the relationship with them. Indeed, since patients lack
Patient
Satisfaction
Stereotypes
toward Health
Care Professionals
Notes: Control variables – patient record: Gender, Age, Degree of Severity, Length of Stay,
Change of Department, Admission Type, Discharge Type, Department; hospital data: Introduction
of Case Management
Patient
Orientation
Patient
Co-creation
(+)
(–)
(+)
(–)
(–)
Figure 1.
Conceptual framework
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the medical expertise to evaluate the appropriateness and quality of care processes, and
might also be overwhelmed by the situation overall due to ill-health, patients place
particular emphasis on personal and interpersonal aspects of healthcare experiences (Bellou,
2010; Berry and Bendapudi, 2007). In other words, the question of whether or not patients
are satisfied with their hospital stay is largely influenced by their evaluation of the
hospitals frontline employees. Supporting this conclusion, evidence shows that sympathy
for physicians is an important predictor of patient satisfaction (Hall et al., 2002). Research
specifically suggests that holding stereotypes about hospital employees tends to lead to
biased evaluations of their qualities, behaviors and performance (e.g. Bogart et al., 2004;
Hekman et al., 2010). Holding stereotypes implies that individuals engage in selective
information processing, i.e. they focus on information consistent with their preexisting
expectations, because such information can be processed more easily and efficiently
(Hamilton and Trolier, 1986; Hilton and von Hippel, 1996). As a consequence, Bogart et al.
(2004) found that positive physician stereotypes (e.g. friendly, competent and sensitive)
increase patient satisfaction, while negative stereotypes toward them (e.g. rude, unskilled
and unintelligent) have the opposite effect. Thus:
H1. The more negative stereotypes customers (i.e. patients) hold toward other actors in
HCSSs (i.e. clinical staff ), the lower their satisfaction will be.
Stereotyping and patient orientation in human-centered service systems
While stereotypes may directly influence how patients evaluate service processes
in HCSSs overall, the current study also considers the possibility of an indirect
relationship mediated by patientsperceptions of two key facets underlying
resource integration and value co-creation in HCSSs. As shown in Figure 1, healthcare
professionalspatient orientation, as perceived by the patient, is the first of these
mediating mechanisms examined.
Service research widely regards customer orientation, which can be defined as the
customersperception of the willingness of company employees to satisfy customer needs
(Walsh et al., 2009, p. 191), as an important driver of customer satisfaction (e.g. Brady and
Cronin, 2001; Hennig-Thurau, 2004). Behaving in a customer-oriented manner (e.g. by acting
in customersbest interest, taking time to answer their questions, or putting extra effort into
solving problems that arise) is particularly important, since the human interactions and
social context of value co-creation play a key role in how beneficiaries (i.e. patients) perceive
value (Brown et al., 2002; Edvardsson et al., 2011). For example, evidence suggests that
service providers perceived to be highly customer oriented receive higher performance
ratings by customers, thereby supporting the satisfaction enhancing effect of customer
orientation (Brady and Cronin, 2001). Not only actual improvements in service delivery and
outcomes, but also affective factors (e.g. customer-oriented employees appear to be more
likeable, warm and trustful) may account for more positive perceptions of value co-creation
processes overall. This argument holds especially true for health services, where patients
are usually unable to adequately judge the actions by medical staff due to information
asymmetries (see Bellou, 2010; Berry and Bendapudi, 2007).
Positive and negative stereotypes, in turn, are likely to shape patientsperceptions of
their caregiverspatient orientation. As mentioned above, stereotypes affect how
information is processed and stored, with individuals seeking to establish consistency
between their preexisting expectations formed by stereotypes and actual experience of
health services (e.g. Hamilton and Trolier, 1986; Hilton and von Hippel, 1996). Thus, holding
positive (negative) stereotypes toward healthcare professionals likely leads patients to
perceive them as interested (disinterested) in their needs. For example, Bogart et al. (2004)
noted that patients who hold negative stereotypes might become anxious when anticipating
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interaction with physicians or nurses, which leads them to avoid contact. This may act as a
self-fulfilling prophecy in that caregivers indeed appear to be inaccessible, uncaring and
disagreeable (see Hilton and von Hippel, 1996) or, to put it differently, not sufficiently patient
oriented. Positive stereotypes can be expected to have the opposite effect. Taken together, it
can be hypothesized that:
H2. Perceived customer (i.e. patient) orientation will mediate the relationship between
stereotypes customers (i.e. patients) hold toward other actors in HCSSs (i.e. clinical
staff) and their satisfaction.
Stereotyping and patient co-creation in human-centered service systems
Moving the vision of patient-centered care from rhetoric to reality is an aspirational goal
across HCSSs like healthcare (Barry and Edgman-Levitan, 2012). After all, it is desirable to
include patients as active co-creators in their own health service, because active patient
involvement is positively associated with perceptions of service quality, well-being and
patient satisfaction (Clayman et al., 2016; Gallan et al., 2013; McColl-Kennedy, Hogan, Witell
and Snyder, 2017; McColl-Kennedy, Danaher, Gallan, Orsingher, Lervik-Olsen and Verma,
2017; McColl-Kennedy, Snyder, Elg, Witell, Helkkula, Hogan and Anderson, 2017), as well as
objective treatment outcomes (e.g. Longtin et al., 2010). In a more general sense, customer
participation is a behavioral construct that measures the extent to which customers
provide or share information, make suggestions, and become involved in decision-making
(Chan et al., 2010, p. 49). In health services, patients may co-create value by discussing their
conditions and symptoms, supporting diagnostic efforts or expressing their treatment
preferences (Gallan et al., 2013).
While the FPs of S-D logic initially postulated customers are always active co-creators of
value (Vargo and Lusch, 2008), this notion has been challenged with Vargo and Lusch (2016)
acknowledging that the absence of a clearly articulated specification of the mechanisms of
[] cooperation involved in the cocreation of value(p. 5) represented a limitation to S-D
logic. Today, S-D logic acknowledges that the ability to actively integrate resources during
value co-creation, especially in health service contexts, requires coordination through
actor-generated institutions(Vargo and Lusch, 2016, p. 18), like informed decision making
(McColl-Kennedy et al., 2012), as well as trust (e.g. Eisingerich and Bell, 2008). It is, therefore,
also unsurprising that not all patients want to, or can be, active participants in health service
(Berry and Bendapudi, 2007; Street et al., 2005). Specifically, this may be due to missing
technical knowledge and inability to learn about healthcare more generally (Hibbert et al.,
2012), patientsill-health (e.g. Longtin et al., 2010), or simply due to the fact that patients
dislike the need to engage with healthcare in the first instance, which leads to avoidance and
denial (Rosenstock, 2005).
Stereotypes influence not only the perception individuals have of others and their
behavior, but also that of an individuals own behavior (e.g. Hilton and von Hippel, 1996).
Therefore, the extent to which a patient holds negative stereotypes toward his or her
healthcare professionals likely determines whether or not a patient is willing to actively
integrate and exchange resources, and thereby co-create value, in the context of an HCSS.
In fact, patients who hold more positive (negative) stereotypes (e.g. approachable vs
arrogant) toward healthcare professionals, are more (less) likely to interact with them
(Bogart et al., 2004), and thus actively participate in health service processes, than those
patients who hold no stereotypes, or more positive ones.
In summary, this study proposes that patientsperceived participation in co-creation is a
key mediating mechanism that links patientsstereotypes and satisfaction.
As discussed, there are strong arguments suggesting that negative stereotypes may
prohibit some patients from taking an active role as co-creators of their own health service,
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whereas positive stereotypes are likely to increase their willingness to co-create value.
In turn, active patient involvement in the co-creation of health care enhances treatment
outcomes (e.g. Longtin et al., 2010) and not least due to self-serving biases patientsquality
perceptions overall satisfaction (Clayman et al., 2016; Gallan et al., 2013). Thus:
H3. Perceived participation in the value co-creation process will mediate the relationship
between stereotypes customers (i.e. patients) hold toward other actors in HCSSs
(i.e. clinical staff ) and their satisfaction.
Methods
This study focuses on the effect of patientsoccupational stereotypes on their satisfaction
with health services and mechanisms mediating this relationship. A public German
healthcare provider that operates two hospitals with over 700 beds, 1,500 employees and
14 clinical departments serves as the studys setting. The health care provider offers a broad
set of clinical services ranging from general, visceral and minimally invasive surgery, stroke
care and emergency medicine to cardiology, neurology and oncology. The study relies on a
matched data set containing survey and electronic patient record data. In January 2015,
1,016 adult inpatients received a paper-based questionnaire, with 307 questionnaires
returned, resulting in a 30 percent response rate. After excluding questionnaires without
answers to the focal constructs 213 usable observations remained for subsequent analyses.
Missing data in some items appeared in less than 5 percent of all observations and were
imputed by using the mean value of the other items in that measure. T-tests were conducted,
which confirmed the absence of any significant differences between respondents and
non-respondents, except for the unsurprising finding that non-respondents were older and
stayed longer in hospital.
Measures
Dependent variable. This study followed the precedence of prior health service research
(e.g. Breidbach et al., 2016), and used a single item developed by Dagger et al. (2007) to
measure patient satisfaction. Using a single item to measure customer satisfaction has been
shown to be valid (Bergkvist and Rossiter, 2007). This study, therefore, relied on a single
item measure capturing patientsoverall satisfaction on a seven-point Likert scale, ranging
from (1) totally disagreeto (7) totally agree.All measures used in this study are reported
in the Appendix.
Independent variables. Following Homburg et al. (2011) and Mikolon et al. (2016), patients
stereotypes toward healthcare professionals were measured using the method suggested by
Gardner (1994), which involved a stereotype differential across seven dimensions. First, a
qualitative pre-study asked ten individuals across a wide age range, educational
backgrounds and experience with healthcare professionals about their perceptions
regarding positive and negative characteristics of healthcare professionals. These
characteristics were then aggregated for use in the survey. Insights from social
psychology, which indicate that the stereotype of a particular occupational group is, in fact,
an image of the individuals performing the job (Glick et al., 1995), were integrated into this
process. The final questionnaire then asked patients about their assessment of healthcare
professionalsabilities and characteristics. In sum, 14 items were used to assess stereotypes.
Items were used twice, once to measure stereotypes toward physicians, and once toward
caregivers such as nurses. Items were re-coded such that the left side of the differential is 7,
indicating strong negative patient stereotypes, and the right side of the differential is 1,
which reflects very positive perceptions of healthcare professionals. For the stereotypes
measure, Cronbachsαwas 0.91, which indicates a high degree of internal reliability
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following the criterion of Nunnally and Bernstein (1994). Finally, the 14 items were
aggregated using their arithmetic means.
Mediating variables. An adapted version of Homburg et al.s (2011) five-item scale was
used to measure Patient Orientation, with items including My treating physicians and
caregivers try to identify my wishes and needs(Cronbachsα¼0.95). To measure a
patients individual perception of being actively involved in the Co-creation of their health
service, the scale developed by Chan et al. (2010) was transferred to the healthcare context.
This scale has been used by other studies before (e.g. Gallan et al., 2013). It includes items
such as During the treatment, I put a lot of effort into expressing my personal needs
(Cronbachsα¼0.86). A seven-point Likert scale ranging from (1) totally disagreeto (7)
totally agreewas used to measure both mediators.
Control variables. This study controlled for potentially confounding factors by matching
archival data from electronic patient records to the survey data. Specifically, prior studies
have found that Gender (Longtin et al., 2010; Street et al., 2005) and Age (Rosén et al., 2001)
might influence perceptions of, and satisfaction with, healthcare outcomes. Furthermore,
patientsclinical Severity was accounted for, as more severe medical conditions usually lead
to more intense interaction between patients and staff. Severity was measured using the
standardized cost weights associated with illnesses in the German healthcare system.
Health conditions have also been linked with patient satisfaction (e.g. Jackspm et al., 2001).
Moreover, this study captured whether a Change of Department took place during
hospitalization and for the overall Length of Stay in days. Longer stays result in more time
to interact with hospital staff, which, in turn, might attenuate or foster their stereotypes and
affect their satisfaction. Patientssatisfaction with their care might also be influenced by the
general characteristics of the hospital. So a dummy set was included to account for the
14 types of clinical department (e.g. internal medicine, surgery). Moreover, the admission
type (e.g. planned stay, emergency), and the discharge type (e.g. regular discharge, transfer
to other hospital) for each patient were included as dummy sets. Finally, Case Management
describes the centralization of processes within a hospital including planning, facilitating
and coordinating care for patients through a single touch point (Somme et al., 2012).
However, not all clinical departments within this study adopted case management, so that
the dummy aimed to control for this.
Analysis
The empirical analyses of this study were performed using ordinary least squares (OLS)
regression computed with Stata
©
15. Mediation analyses were performed using the
established procedure developed by Baron and Kenny (1986). In addition, bootstrap tests
were conducted to test the significance of the indirect effects in mediated models (Preacher
and Hayes, 2004), which is a superior choice when compared to the Sobel test (Zhao et al.,
2010). Multicollinearity was tested by estimating variance inflation factors, which met Hair
et al.s (1995) requirement of being below 10. An additional condition index test was
conducted, which indicated that multicollinearity was not an issue in the data, because all
values were lower than Belsley et al.s (1980) threshold of 30.
The measures of all latent constructs (stereotypes toward healthcare professionals,
perceived patient orientation and patient participation in co-creation) were validated, with
all measures possessing adequate internal reliability. Composite reliabilities were above the
threshold of 0.6 (Bagozzi and Yi, 1988). To test whether the constructs were conceptually
distinct from one another, discriminant validity was assessed using the average variance
extracted (AVE). All constructs had an AVE exceeding the squared multiple correlations
between the constructs meeting the criterion defined by Fornell and Larcker (1981)
(see Table AI). The items of the scales were aggregated using their arithmetic means.
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The measures of the dependent and independent variables in this study stem from the
same survey instrument, which can increase the risk of common method bias (e.g. Podsakoff
et al., 2003). Hence, in order to reduce a possible common method bias, the dependent and
independent variables were positioned in separate parts of the questionnaire. Second,
different response formats were used, i.e., semantic differentials for the independent
variable, and a seven-point Likert scale for the dependent variable. Third, including only
established measures ensured the reliability and validity of the approach adopted. Fourth,
the questionnaire contained a preface to explain to participants that there were no right or
wrong answers, and encouraged them to answer honestly.
Results
Table I contains descriptive statistics and pairwise correlations. On average, patients were
61.71 years old with 49 percent being female. The average duration of a patients
hospitalization was 8.87 days with a standard deviation of 6.17 days. On the seven-point
scale ranging from (1) very positive to (7) very negative stereotypical perceptions of
caregivers, the average value was 2.55, indicating that positive stereotypes toward
caregivers were more prevalent among patients than negative ones. The mean level of
patient satisfaction was 5.65 with a standard deviation of 1.42. Furthermore, Table I shows a
mean of 5.78 for patientsperception of their healthcare providers patient orientation, and a
mean of 4.57 for patientsperceived participation in the co-creation of their own health
service on seven-point Likert scales. Importantly, perceived patient orientation and
co-creation are both negatively and significantly correlated with the extent to which patients
hold negative stereotypes toward their healthcare professionals.
Table II depicts the results of the regression analyses. In order to reduce complexity,
findings are reported for the negative side of stereotypes only. The bipolar nature of the
stereotype scale implies inverse relationships for positive stereotypes. Model 1 serves as the
baseline model. Model 2 introduces patientsstereotypes, showing a negative and significant
association between patientsnegative stereotypes toward health care professionals and
their satisfaction (b¼0.8131, po0.01). H1, which stated that the more negative
stereotypes are, the lower patientssatisfaction will be, is thus supported[3].
Variable (1) (2) (3) (4) (5) (6) (7) (8) (9) (10)
1. Satisfaction 1.00
2. Stereotypes 0.62*** 1.00
3. Patient
Orientation 0.73*** 0.67*** 1.00
4. Co-creation 0.13 0.24*** 0.23*** 1.00
5. Gender 0.04 0.03 0.00 0.07 1.00
6. Age 0.05 0.02 0.02 0.03 0.28*** 1.00
7. Severity 0.02 0.02 0.04 0.06 0.12 0.24*** 1.00
8. Change of
Department 0.06 0.07 0.07 0.13 0.09 0.25*** 0.04 1.00
9. Length of Stay 0.01 0.09 0.03 0.02 0.19** 0.36*** 0.57*** 0.25*** 1.00
10. Case
Management 0.03 0.16* 0.07 0.10 0.09 0.09 0.31*** 0.02 0.27*** 1.00
Mean 5.65 2.55 5.78 4.57 0.51 61.71 1.31 0.09 8.87 0.54
SD 1.42 1.05 1.18 1.36 0.50 18.28 1.02 0.29 6.17 0.50
Minimum 1.00 1.00 1.40 1.00 0.00 13.00 0.21 0.00 0.90 0.00
Maximum 7.00 6.32 7.00 7.00 1.00 91.00 8.75 1.00 40.65 1.00
Notes: n¼213. Dummy sets for admission types, discharge types and departments are not reported. *po0.1;
**po0.05; ***po0.01
Table I.
Descriptive results
and pairwise
correlations
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Model 1 Model 2 Model 3 Model 4 Model 5 Model 6 Model 7
Variable
Patient
satisfaction Patient satisfaction Patient orientation Patient satisfaction Patient co-creation Patient satisfaction Patient satisfaction
Constant 5.7233*** (1.3003) 8.7355*** (0.7946) 8.5509*** (0.7107) 2.9714*** (1.0620) 7.1695*** (1.0710) 8.4997*** (0.9515) 3.086*** (1.0942)
Controls
1. Gender 0.0011 (0.2227) 0.0532 (0.1706) 0.0448 (0.1309) 0.0834 (0.1434) 0.1064 (0.1899) 0.0567 (0.1721) 0.0814 (0.1442)
2. Age 0.0075 (0.0074) 0.0073 (0.0057) 0.0021 (0.0043) 0.0059 (0.0050) 0.0041 (0.0061) 0.0072 (0.0057) 0.006 (0.0050)
3. Severity 0.0633 (0.1315) 0.1133 (0.0991) 0.1005 (0.0768) 0.1810* (0.0919) 0.1465 (0.1273) 0.1181 (0.1009) 0.1784* (0.0922)
4. Change of
Department 0.1900 (0.4128) 0.0517 (0.2700) 0.1287 (0.1921) 0.0350 (0.2575) 0.5314 (0.4251) 0.0342 (0.2698) 0.0249 (0.2560)
5. Length of Stay 0.0108 (0.0244) 0.0225 (0.0185) 0.0014 (0.0135) 0.0234 (0.0169) 0.0084 (0.0183) 0.0222 (0.0185) 0.0236 (0.0170)
6. Case
Management 1.8249 (1.2086) 1.0722 (0.6735) 0.3356 (0.4897) 1.2984** (0.5506) 2.0192*** (0.5320) 1.1386 (0.6991) 1.2595** (0.5636)
7. Admission
Type Dummies
Yes*** Yes** Yes** Yes** Yes Yes** Yes**
8. Discharge Type
Dummies
Yes Yes*** Yes Yes** Yes*** Yes*** Yes**
9. Department
Dummies
Yes** Yes** Yes** Yes** Yes*** Yes** Yes**
Main Effect
10. Stereotypes 0.8131*** (0.1091) 0.7608*** (0.0983) 0.3002*** (0.0987) 0.3456*** (0.0989) 0.8017*** (0.1117) 0.3046*** (0.0988)
Mediators
11. Patient
Orientation 0.6741*** (0.0860) 0.6773*** (0.0876)
12. Co-creation 0.0329 (0.0663) 0.0198 (0.0466)
Total
Observations
213 213 213 213 213 213 213
F-statistic 1.4845* 7.7321*** 9.1605*** 13.8436*** 2.5383*** 7.3651*** 13.1876***
R
2
0.1339 0.4595 0.5018 0.6158 0.2182 0.4603 0.6161
Adj. R
2
0.0437 0.4001 0.4470 0.5713 0.1322 0.3978 0.5694
Notes: Unstandardized estimates from ordinary least squares (OLS) models. Robust standard errors reported in parentheses. Model 1 is the baseline model. Model 2
establishes the main effect of stereotypes on patient satisfaction (path c in mediation analysis). Models 3 and 5 report the effect of stereotypes on the mediators (path a in
mediation analysis). Models 4 and 7 report the analysis of the mediators and stereotypes on patient satisfaction (paths b and c'in mediation analysis). *po0.10;
**po0.05; ***po0.01
Table II.
Regression analyses
explaining patient
satisfaction
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To test the mediation proposed by H2, this study follows Baron and Kenny (1986). The test
of H1 fulfills the first condition of the Baron and Kenny (1986) approach, as it shows a
significant association between stereotypes patients hold toward their healthcare
professionals (independent variable), and patientssatisfaction (dependent variable).
In a second step, this study tested whether stereotypes patients hold toward their
healthcare professionals are linked to the first mediator, that is the patient orientation by
healthcare professionals, as perceived by patients. Model 3 shows a significant and negative
association (b¼0.7608, po0.01). Finally, Model 4 explores how stereotypes and the
perceived patient orientation impact on patient satisfaction. The intention underlying Model
4 is, therefore, to examine whether the effect of stereotypes patients hold toward their
healthcare professionals on their satisfaction is mediated by their perception of a healthcare
provider being patient orientated. For one, this analysis indicated that a significant effect of
perceived patient orientation on patientssatisfaction exists (b¼0.6741, po0.01), and also
that a significant effect of patientsstereotypes toward their healthcare professionals on
their satisfaction exists (b¼0.3002, po0.01). A bootstrap test of the indirect effect with
10,000 replications is significant (0.5510; bias-corrected and accelerated 95% confidence
interval: 0.7421; 0.3860). The results indicate partial mediation (Baron and Kenny, 1986).
H2 is thus supported.
Tests for H3 followed the same procedure. Model 5 shows that holding negative
stereotypes is associated with lower levels of patient co-creation (b¼0.3456, po0.01) in
the health care process. Model 6 simultaneously tests the effect of patientsstereotypes on
their level of co-creation as well as the co-creation-patient satisfaction link. While there was
still the expected negative relationship between stereotypes and patient co-creation
(b¼0.8017, po0.01), patient co-creation, in turn, had no significant effect on patient
satisfaction (b¼0.0329, ns). The conditions for mediation are therefore not met.
A statistically insignificant bootstrap test with 10,000 replications of the indirect effect
(0.0243; bias-corrected and accelerated 95% confidence interval: 0.0842; 0.0084) confirms
this conclusion. H3 is thus not supported. Model 7 shows the full model containing both
mediators. And while the coefficients change slightly, the pattern of the results remains
unchanged supporting the previous analyses.
Finally, to test the robustness of the results, the dependent variable was changed. The
survey contained two additional items to reflect patient satisfaction, which were taken from
McKay et al. (2011) and De Ruyter et al. (1997). These analyses yielded results that were
qualitatively similar to the main analysis, indicating that all findings are robust for different
measures of the dependent variable. As the measure of patientsoccupational stereotypes
comprised a set of seven items patients answered separately with regards to physicians
(mean of 2.47 on scale from 1 (very positive) to 7 (very negative), standard deviation of 1.16)
and caregivers (mean of 2.62, standard deviation of 1.13), distinct stereotype measures were
computed for each occupational group. Although the means of the two groups differed
significantly with caregivers being perceived slightly less positively (t(212) ¼2.36,
po0.05), these more granular analyses did not yield any significant differences between
both groups with regards to the key relationships of interest.
Discussion
Theoretical implications
This study has responded directly to Ostrom et al.s (2015) service research priority of better
understanding value creation, especially as it pertains to multi-actor, network and
collaborative contexts like HCSSs set in the context of healthcare. It also answered calls for
service research to investigate the changing role of customers (i.e. patients) as active
co-creators of value more specifically (McColl-Kennedy, Hogan, Witell and Snyder, 2017;
McColl-Kennedy, Danaher, Gallan, Orsingher, Lervik-Olsen and Verma, 2017;
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McColl-Kennedy, Snyder, Elg, Witell, Helkkula, Hogan and Anderson, 2017), and ultimately
contributes to the just emerging more realistic understanding of customers as boundedly
rational actors in service settings (Santos and Spring, 2015).
This study sets out to explore if and how occupational stereotyping affects the
satisfaction of patients as co-creators of value when interacting with clinical staff, which
resulted in empirical contributions and insights across three levels. First, at a broad level,
this study contributes to extant service research by providing additional empirical
evidence on the role of stereotypes in service processes. When compared to related
constructs such as customer expectations (e.g. Zeithaml et al., 1993), occupational
stereotypes have received far less attention in the literature, with Hekman et al. (2010) and
Luoh and Tsaur (2011) providing some notable exceptions. However, the complexity of
service processes increases and boundedly rational customers can be expected to rely on
cognitive shortcuts when making sense of these experiences (Vargo and Lusch, 2016).
The present study supports the notion that stereotypes toward groups of service
providers are a powerful predictor of customer perception, judgment and behavior.
It specifically extends the few existing studies on stereotypes toward physicians (Bogart
et al., 2004) by exploring the link between patientsstereotypes toward frontline employees
beyond the specific patientphysician interface (e.g. nurses, physiotherapists).
As patientssatisfaction is likely to be affected not only by their perceptions of and
interactions with physicians, but also other employee groups involved in the health
service, the more encompassing conceptualization of stereotypes proposed in this study
contributes to a more realistic picture of their role and impact.
Second, perhaps most importantly, this study provides novel insights into how
occupational stereotypes take effect. To date, research examining stereotypes in service
settings (Hekman et al., 2010; Luoh and Tsaur, 2011) predominantly treated the process
through which stereotypes influence meaningful outcomes of service encounters
(e.g. customer satisfaction, retention) as a black box. This study, therefore, examined the
influence of two mediating variables that capture patientsperception of both healthcare
professionals(patient orientation), as well as their own behavior (patient participation), in
the co-creation of health service. While the findings show that holding negative (positive)
stereotypes is associated with both perceptions of reduced (increased) patient orientation
and participation in co-creation, only patient orientation was found to partially mediate the
link between stereotypes patients hold toward frontline employees in HCSS and their own
satisfaction with a health service. On the one hand, this finding reminds us about the
importance of focusing on the social context in which value co-creation takes place
(Edvardsson et al., 2011). On the other hand, it suggests that occupational stereotypes are a
highly relevant phenomenon for organizations seeking to be perceived as customer oriented.
A potential explanation for the strong stereotypes-customer (i.e. patient) satisfaction
relationship observed in this study may be that stereotypes act as a self-fulfilling prophecy
(Hilton and von Hippel, 1996). Put differently, it is likely that customers with preexisting
negative (positive) stereotypes such as arrogance, incompetence or cold-heartedness
(humility, competence or warmness) may avoid (seek) interaction with service employees,
which causes them to believe that they are actually less (more) customer oriented.
Third, this research introduces stereotypes as a new antecedent of participation in
co-creation, thereby extending the growing body of work concerned with factors influencing
how value is co-created in a joint process of resource exchange and integration (Chan et al.,
2010). The observation that negative (positive) stereotypes decrease (increase) the extent to
which customers are active co-creators of value in their own health service suggests that
stereotypes primarily affect the human dimension of service. However, contrary to H3, the
results of this study do not indicate that the perception of active participation in co-creation
influences patient satisfaction, and thus acts as a mediator between patientsstereotypes
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and their satisfaction. This is particularly interesting since emerging empirical evidence
suggests that co-creation increases customer satisfaction (e.g. Chan et al., 2010). While
this effect has also been observed in the context of healthcare (see Clayman et al., 2016;
McColl-Kennedy, Hogan, Witell and Snyder, 2017; McColl-Kennedy, Danaher, Gallan,
Orsingher, Lervik-Olsen and Verma, 2017; McColl-Kennedy, Snyder, Elg, Witell, Helkkula,
Hogan and Anderson, 2017), it appears plausible that the unique features of inpatient
hospital services explain why no such effect was observed in the present study. Given the
complex nature of hospital care, information asymmetries, as well as anxiety and stress
associated with serious health issues (McColl-Kennedy, Hogan, Witell and Snyder, 2017;
McColl-Kennedy, Danaher, Gallan, Orsingher, Lervik-Olsen and Verma, 2017;
McColl-Kennedy, Snyder, Elg, Witell, Helkkula, Hogan and Anderson, 2017), patients may
simply view themselves as not being capable of performing the role as active co-creators of
value, as previously suggested, and now acknowledged by Vargo and Lusch (2016).
If patients do not believe that they can make a meaningful contribution, it is unlikely that
opportunities to participate have much influence on their overall evaluation of the hospital
service. In support for this conclusion, Chan et al (2006) found that the effect of customer
participation on customer satisfaction is fully mediated by customer value
creation. Accordingly, participation alone seems not to be the key to increased patient
satisfaction customers have to believe that their participation actually improves service
outcomes, as well as the interactions they have with service providers.
In conclusion, stereotypes provide service researchers with a promising construct
through which to view interactions in complex HCSSs like health care. The present study
contributes to a better understanding of this cognitive shortcut that is used by service
customers and providers alike (e.g. Mai and Hoffmann, 2011). Ultimately, the findings
presented here contribute new insights into how economic actors co-create value (e.g. Payne
et al., 2008), and represents an important starting point for future research that can also
showcase the practical application of S-D logic (Friend and Malshe, 2016).
Managerial implications
Occupational stereotyping has a significant impact on value co-creation processes in HCSSs,
and should, therefore, be taken seriously not only by managers, but also by frontline
employees who play a central role in shaping patientshealth service experience (Berry and
Bendapudi, 2007). The empirical findings of this study indicate that positive stereotypes
result in desirable outcomes like increased patient satisfaction, but also suggest that
patientsnegative stereotypes require specific managerial attention. Three
recommendations for how the impact of negative occupational stereotypes in HCSSs
could be reduced emerge: increasing the quantity and quality of interaction between
caregivers and patients, reducing the complexity of health service processes, and acting
contrary to occupational stereotypes.
First, stereotyping necessarily implies a depersonalization of physicians and other
caregivers, i.e. patients do not evaluate these actors based on their personal qualification
and performance, but rather based on group stereotypes (e.g. Bogart et al., 2004). To
overcome this tendency and bring an individual caregivers human characteristics into the
foreground, this study suggests that increasing the time caregivers and patients spend with
and learn about one another could be a promising approach.
Second, unnecessarily complex service processes with multiple touch-points increase the
cognitive load of patients (Breidbach et al., 2016), and thereby provide a fertile ground for
stereotypes to be activated as cognitive shortcuts in service interactions. Reducing the
complexity of interactions in HCSSs would be a promising approach to address this issue.
For example, hospitals could reduce the number of different physicians and nurses involved
in the treatment of the same patient or ensure that diagnostic and treatment information is
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provided in an understandable manner. In this regard, it will be important to provide
training to frontline employees to increase their awareness of patients’–as well as their
own stereotypes and how to deal with them. This could be, for instance, achieved through
perspective-taking training, i.e. confronting employees with customersperceptions about
them (Mikolon et al., 2016).
Third, being aware of negative stereotypes, such as that physicians are arrogant, can
enable caregivers to act contrary to these stereotypes. Ashforth et al. (2007) observed that
members of stigmatized occupations (e.g. used car salespeople) use this approach to improve
customer perceptions of their occupation, and develop trusting relationships. In particular,
Hilton and von Hippel (1996, p. 242) noted: reactions to individual group members are
based on a comparison between the prototype and the individual, any features, even
nondiagnostic ones, that reduce the similarity between the individual and the prototype
should decrease reliance on the stereotype.As such, counterstereotypical and
unconventional behaviors might be a way to improve relationships with customers
holding unfavorable occupational stereotypes.
Limitations and future research
This study is subject to some empirical and conceptual limitations that suggest promising
avenues for future research. First, the results hold first and foremost for the specific context
of German inpatient care. To assess the generalizability of the substantive conclusions,
replication studies in other settings are needed. There is hence a clear need for future
research on how patientsstereotypes regarding clinical professionals shape service
outcomes in settings such as inpatient care in other countries, or even outpatient and
general care.
Second, the occupational stereotype scale used in this study captures both negative and
positive stereotypes of patients toward caregivers. However, future research could provide a
more fine-grained discussion of the opposing effects of positive and negative stereotypes in
service interactions. For example, it is plausible that there may be certain conditions where
positive stereotypes could be associated with detrimental outcomes, and negative
stereotypes could be associated with positive effects. Thus, examining contingency factors
that influence the consequences of stereotyping would be an important future avenue.
Third, cross-sectional designs like the one employed by this study generally make it
difficult to disentangle correlation and causation. Longitudinal studies that trace patients
over time and across multiple health service interactions would, therefore, complement
the present work. It would be particularly desirable to measure patientsstereotypes at
different points in time. By doing so, future studies could provide an even better
understanding of how, and especially when, stereotypes affect service interactions.
While measuring stereotypes and customer/patient evaluations of the service
simultaneously during the service experience is consistent with prior work (e.g. Bogart
et al., 2004), this approach neglects potential within-person variance in stereotypes over
time (see Garcia-Marques et al., 2006).
Fourth, data limitations made it unfeasible to separate patientsstereotypes toward
clinical professionals from their expectations regarding specific health services. Future
research could attempt to capture these related concepts separately to illuminate their subtle
interplay. Even though this will be a challenging endeavor that requires granular data
access, it constitutes an avenue worth pursuing. Finally, this study focuses on patients
stereotypes toward health professionals. However, these individuals may also hold
stereotypes toward patients (Van Ryn and Burke, 2000), which could have similar
behavioral consequences like patientsstereotypes, and these two types of stereotypes
might interact in non-obvious ways. Exploring the ways in which stereotypes impact HCSSs
has therefore only just begun.
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Notes
1. This study builds on the precedence of prior health service research (e.g. McColl-Kennedy et al.,
2012; Sweeney et al., 2015; Breidbach et al., 2016), and adopts a lens of service-dominant (S-D) logic
to assume that value is co-created by multiple actors, [] including the beneficiary(Vargo and
Lusch, 2016, p. 18), in a joint process that culminates in phenomenological value experiences
(Vargo and Lusch, 2008, 2016).
2. Compared to outpatient care, stereotypes toward caregivers should be more prevalent and
influential in inpatient hospital settings. Inpatients tend to have more serious health issues,
experience more complex sequences of care and interact with a greater number of different
caregivers than outpatients (Berry and Bendapudi, 2007). As such, inpatients can be expected to
experience greater cognitive overload, anxiety and stress (see McColl-Kennedy, Hogan, Witell and
Snyder, 2017; McColl-Kennedy, Danaher, Gallan, Orsingher, Lervik-Olsen and Verma, 2017;
McColl-Kennedy, Snyder, Elg, Witell, Helkkula, Hogan and Anderson, 2017), which, in turn,
provides a fertile ground for stereotyping (Hilton and von Hippel, 1996).
3. To check the robustness of the effect of patientsstereotypes on their satisfaction, an additional
study using a different patient sample from the same hospital group was conducted. As shown in
Table AII in the Appendix, this study provided additional support for H1. Model 2 shows that
patientsstereotypes toward healthcare professionals are negatively and significantly associated
with patient satisfaction (b¼0.5864, po0.01). This effect is practically meaningful, since an
increase of 1 point in patientsnegative stereotypes toward healthcare professionals is associated
with a decrease in their satisfaction by 0.5864 points on a seven-point Likert scale.
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Appendix. Scale items for construct measurement
(1) Patientsstereotypes toward their health care professionals (data source: patients) own
development as suggested by Gardner (1994); seven-point semantic differential scale:
My physicians/caregivers have (1) little or (7) substantial technical expertise.
My physicians/caregivers (1) are unable or (7) able to explain medical issues.
My physicians/caregivers make (1) many or (7) no mistakes.
My physicians/caregivers take (1) little or (7) a lot time for the individual patient.
My physicians/caregivers are (1) lazy or (7) hardworking.
My physicians/caregivers are (1) arrogant or (7) modest.
My physicians/caregivers are interested in (1) their own or (7) patientswelfare.
(2) Patientssatisfaction (data source: patients) based on Dagger et al. (2007); totally disagreeto
totally agreeon a seven-point Likert scale:
Overall, I am satisfied with the hospital and the service it provides.
(3) Patient orientation (data source: patients) based on Homburg et al. (2011); totally disagreeto
totally agreeon a seven-point Likert scale:
My treating physicians and caregivers try to identify my wishes and needs.
My treating physicians and caregivers act in my interest.
My individual needs are important to my treating physicians and caregivers.
My treating physicians and caregivers recommend treatments that mitigate my
complaints as best as possible.
My treating physicians and caregivers try to find the best possible treatment for me.
(4) Patientsperception of their participation (data source: patients) based on Chan et al. (2010);
totally disagreeto totally agreeon a seven-point Likert scale:
I spend a lot of time sharing information about my needs and opinions with my treating
doctors and caring nurses.
I put a lot of effort into expressing my personal needs during the health care process.
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I provide suggestions for improving the health care outcome.
I have a high level of participation in the health care process.
I am very much involved in deciding how the health care should be provided.
About the authors
Antje Sarah Julia Huetten is a former Post-Doctoral and PhD Student within the TIME Research Area
at RWTH Aachen University. Her research interests include the role of stereotypes, services and
relationship marketing.
David Antons is Co-director of the Institute for Technology and Innovation Management in the
TIME Research Area at RWTH Aachen University. He is the German equivalent of an Associate
Professor and holds a PhD from RWTH Aachen University. His research has been published in
journals such as the Academy of Management Review, Journal of Management,Journal of Service
Research,Journal of Product Innovation Management and Academy of Management Perspectives.
Stereotypes
Patient
orientation
Patient
participation
Fornell
Larcker ratio Cronbachsα
Composite
reliability
Stereotypes 0.520 0.975 0.936 0.937
Patient orientation 0.507 0.823 0.667 0.958 0.959
Patient participation 0.083 0.089 0.576 0.155 0.865 0.869
Notes: Italic values on the diagonal show the AVE. Numbers below the diagonal show squared construct
correlations
Table AI.
Discriminant
validity analysis
Model 1 Model 2
Variable Patient satisfaction Patient satisfaction
Constant 8.4806*** (0.9516) 9.9740*** (0.9601)
Controls
1. Gender 0.2278 (0.2137) 0.2252 (0.1770)
2. Age 0.0000 (0.0070) 0.0056 (0.0062)
3. Severity 0.1317 (0.0863) 0.0718 (0.0751)
4. Change of Department 0.3349 (0.4463) 0.2807 (0.4244)
5. Length of Stay 0.0203 (0.0142) 0.0095 (0.0120)
6. Case Management 0.0297 (0.5478) 0.0126 (0.5160)
7. Admission Type Dummies Yes** Yes**
8. Discharge Type Dummies Yes*** Yes***
9. Department Dummies Yes*** Yes***
Main effect
10. Stereotypes 0.5864*** (0.1116)
Total observations 160 160
F-statistic 2.4795** 6.6041***
R
2
0.2158 0.4266
Adj. R
2
0.1094 0.3441
Notes: Unstandardized estimates from ordinary least squares (OLS) models. Robust standard errors reported
in parentheses. *po0.10; **po0.05; ***po0.01
Table AII.
Robustness check:
regression analyses
explaining patient
satisfaction
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Christoph F. Breidbach is Lecturer (Assistant Professor) at the University of Melbourne, School of
Computing and Information Systems. His publications to date appeared in the Journal of Service
Research,Industrial Marketing Management,Managing Service Quality,The Service Industries Journal,
Service Science,Marketing Theory and other outlets. He serves on the editorial boards of the Journal of
Service Research,Journal of Service Theory and Practice and the Journal of Business Research.
Erk P. Piening is Professor of Management at the Gutenberg School of Management and
Economics, Johannes Gutenberg University Mainz. He received his PhD from Leibniz University
Hannover. His current research interests include strategic human resource management, social
evaluations, open innovation and entrepreneurial learning, with special emphasis on the underlying
microfoundations. His research has been published among others in Academy of Management Review,
Journal of Applied Psychology, Journal of Product Innovation Management and Human Resource
Management Review.
Torsten Oliver Salge is Professor of Innovation, Strategy and Organization and Co-director of the
Institute for Technology and Innovation Management in the TIME Research Area at RWTH Aachen
University. He received his PhD from the University of Cambridge and has held (visiting)
appointments at universities in Auckland, Buenos Aires, Bochum, Cambridge, Duisburg, Oxford and
Philadelphia. His current research interests include collaborative innovation, organizational search and
learning from performance feedback. Recent contributions have been published in journals such as
Academy of Management Review, Journal of Applied Psychology,Journal of Management,Journal of
Product Innovation Management,Journal of Service Research,MIS Quarterly and Research Policy.
Torsten Oliver Salge is the corresponding author and can be contacted at: salge@time.rwth-aachen.de
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Occupational
stereotypes in
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... Furthermore, service ecosystems have been confused with networks (McColl-Kennedy et al., 2012) and understood from different theoretical positions (Adner, 2017;Autio & Thomas, 2020). The confusion is even more pronounced as service systems continue to be reframed in novel ways, such as smart service systems (Han & Park, 2019), healthcare service systems (Anderson et al., 2019), human-centred service systems (Huetten et al., 2019), and public service systems (Eriksson et al., 2020). ...
... Technology in such systems enables interactions among multiple actors and favours the implementation of individualised value propositions, thus facilitating value co-creation. On the other hand, some researchers discuss instead human-centred service systems (Huetten et al., 2019), such as hospitals, dominated by human behaviour, human cognition, and human emotions (Maglio et al., 2015). ...
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High academic interest and numerous theoretical and practical studies on service systems and service ecosystems, paired with the accelerated evolution of the service (eco) system concept, have resulted in complex research in this field. Multiple perspectives from which service systems were studied added to this complexity and inadvertently produced conceptual confusion regarding service (eco) systems. This literature review addresses this confusion by focusing on the evolution of service systems to service ecosystems to consolidate and clarify the field. Therefore, this article's purpose is to systematise the extant research on service (eco) systems and indicate future research directions based on the analysis. Specifically, the article systematically reviews 770 publications on service (eco) systems from 2020 and earlier and identifies the main research topics (focusing on service [eco] systems’ constituent elements, inherent processes, and outcomes), theoretical perspectives, and bridging elements, and suggests future research based on the review results. The article concludes by providing a foundation for continued research emerging from the analysis, with emphasis on five aspects that may stimulate new avenues of research: service ecospheres, service ecosystem simplicity, failures of service ecosystems, paradox in service ecosystems, and panarchy and service ecosystems.
... Stereotypes are biased "beliefs about the characteristics, attributes and behaviors of members of certain groups" (Hilton and von Hippel, 1996, p. 240). They are adopted to make quick evaluations about others in an attempt to reduce situational complexity and save an individual's cognitive resources (Huetten et al., 2019;Taylor, 1981). They are usually associated with an individual's gender, physical appearance, race, ethnicity and country of origin (Baltes and Rudolph, 2010). ...
... The role of stereotypes has been widely acknowledged in the marketing literature and they have been found to influence a wide array of attitudes and behaviors in several service contexts (Baltes and Rudolph, 2010;Fiske and Taylor, 1991) and industries (Grandey et al., 2019;Hekman et al., 2010;Huetten et al., 2019). Specifically, individuals tend to hold general biases and pre-existing stereotypes towards frontline service employees based on their race and other demographic or physical characteristics. ...
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Purpose. Academic research has supported the belief that consumers undertip minority race service workers due to implicit racial biases. However, there has been less focus in examining possible moderating factors. This paper fills this gap by analyzing the role of direct and indirect experience in tipping frontline service workers from a minority background. Given the prominence of customer ratings on digital service platforms and the perception that African-Americans are discriminated against, we look at the interplay of interaction length (direct experience) and customer ratings (indirect experience) on the relationship between race and tipping. Design/methodology/approach. An expectancy disconfirmation framework was developed and tested with a sample of 360 US participants in an online experiment. The experiment followed a 2 x (race: African-American versus Caucasian) x 2 (direct experience: limited versus extensive) x 3 (indirect experience: absent versus positive versus negative customer rating) design. Findings. We found consumers who have extended direct experience (longer service interaction) and no indirect experience (absent customer ratings) tipped African-Americans more than Caucasians. Interestingly, this effect is reduced in the presence of indirect experience (customer ratings). Lastly, where the consumer lacks direct experience (shorter service interaction) but is exposed to positive indirect experience (positive customer ratings), consumers tip African-Americans more. Originality/value. This is the first paper that examines the role of direct and indirect experience in the relationship between race and tipping. Based on our findings, we provide several contributions, including recommendations to reduce inequalities arising from implicit racial bias on digital service platforms.
... Second, it is important to formulate, articulate, and implement a digital transformation strategy in conjunction with all actors in one's business ecosystem, thus avoiding misunderstandings that can arise, for example, from stereotypes individuals may hold (Huetten et al., 2019). We highlight the importance of building shared understanding, internal legitimacy, and aligned business goals. ...
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The nature, scope, and impact of digital transformation reaches well beyond the boundaries of a single firm. This suggests information systems research should consider how digital transformation unfolds within business ecosystems that consist of multiple interdependent firms, and how this process can ideally be managed. We pursue this research opportunity by introducing orchestration as a concept through which to view digital transformation in business ecosystems, and by presenting empirical insights from a longitudinal in-depth case study that highlights how a focal firm became the orchestrator of digital transformation in its business ecosystem. We explain that becoming an orchestrator of digital transformation occurs through three distinct phases: initiating, opening-up, and integrating. We also identify the interplay of activities by which a focal firm strategizes, mobilizes, and aligns other actors and their resources, as it orchestrates the digital transformation of its business ecosystem. We conclude by outlining how our work serves as an important foundation for future information systems research and offer managerial guidelines outlining how to orchestrate digital transformation processes within business ecosystems.
... Interacting with other agents (such as medical staff, companions, nurses, first-line employees and other patients) affects perceived service quality satisfaction (Kim, 2019). Huetten et al. (2019) studied the impact of occupational stereotypes held by customers on value co-creation processes in HCSSs, such as hospitals or healthcare centers. Furthermore, research in this line aims to identify how this interactive process is facilitated and supported (Breidbach et al., 2016). ...
Article
Purpose Given the growing importance of the relationship between customer value co-creation and customer satisfaction, it is essential to assess the implications of this connection from both a managerial and an academic perspective. The literature on this link has grown enormously in recent years. However, there lacks an integrative framework to improve its understanding. Based on the use of bibliometric techniques, the purpose of this article is threefold: firstly, to shed light on the relationship's knowledge structure by identifying the main clusters of topics; secondly, to propose an integrative conceptual framework and finally, to identify future avenues of research. Design/methodology/approach The authors analyze a database of 133 recent documents dealing with this pairing to address this gap. A bibliometric coupling methodology was used. Additionally, an in-depth analysis of centrality, density and citations for the different clusters identified in the last years was performed. The authors characterize each group in the knowledge map of the relationship. Findings This bibliometric analysis identified seven thematic clusters. Three of these, with a more transversal nature, have fostered the growth of this literature. The subsequent clusters used theoretical frameworks present in the first three clusters, adapting them to the specific circumstances analyzed, following different patterns of evolution. The authors present the behavior of the citations in each cluster over recent years, analyzing their intellectual base, trends and development potential. Originality/value Derived from their findings, an integrative conceptual framework for explaining the knowledge structure of research in value co-creation and the customer satisfaction literature is proposed. The authors identify main topics by clusters and then detect research gaps and propose new research avenues for the future.
... This provides future researchers with the opportunity to examine the boundary conditions pertaining to ICT-enabled national development. For instance, future research could focus on constructs such as trust, social capital, or stereotypes (Huang et al., 2017;Huetten et al., 2019;Kim et al., 2009) multiple stakeholders hold towards digital technologies (Someh et al., 2019). ...
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Are centralised or decentralised strategies more suitable to address a developing nation's socio‐economic challenges through information and communication technology (ICT)? We respond to this long‐standing question by conceptualising ICT‐enabled national development as a multi‐level social process and by drawing on empirical findings from a natural experiment set in the context of health information system projects in Indonesia. Our study demonstrates that successful ICT‐enabled national development is not contingent on pursuing one strategy or the other but on how micro‐level actors interpret, and subsequently respond to, these strategies and the local changes they trigger. Our findings indicate that centralisation and decentralisation are complementary rather than competing strategies to ICT‐enabled national development because, if integrated into a hybrid strategy, decentralisation enables local communities to achieve national development outcomes commonly attributed to centralisation. As such, our work provides empirical evidence, explanations and new theoretical insight into the wider ‘centralisation versus decentralisation’ debate, while also outlining avenues for future research and guidelines for policymakers.
... Second, there is some evidence that consumers rely on occupational stereotypes to infer the warmth and competence of frontline employees. For instance, Hareli et al. (2013) demonstrate that people perceive doctors (versus no occupation) as warmer and more competent, while Huetten et al. (2019) show that patients' occupational stereotypes affect their satisfaction with physicians. ...
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Purpose Longitudinal studies have shown that consumer satisfaction has increased over the last 15 years, whereas trust and loyalty have decreased during the same period. This finding contradicts the trust–value–loyalty model (TVLM), which posits that higher satisfaction increases consumers' trust, value and loyalty levels. To explain this counterintuitive trend, this study draws on models of trust formation to integrate the stereotype content model and the TVLM. It argues that consumers' occupational and industry stereotypes influence their trust, value and loyalty judgments through their trusting beliefs regarding frontline employees and management practices/policies. Design/methodology/approach The study was conducted among 476 consumers who were randomly assigned to one of five service industries (apparel retail, airlines, hotels, health insurance or telecommunications services) and asked to rate their current service provider from that industry. Findings The results suggest that both occupational and industry stereotypes influence consumers' trusting beliefs and trust judgments, although only the effects of industry stereotypes are transferred to consumers' loyalty judgments. Research limitations/implications The results of the study indicate that industry stereotypes have become increasingly negative over the last decades, which has a dampening effect on the positive effects of satisfaction. Practical implications This study provides guidelines for practitioners regarding the management of frontline employees and the development of consumer trust, value and loyalty. Originality/value This is the first study to propose and test an explanation for the counterintuitive trend concerning customer satisfaction, trust and loyalty. It is also the first to examine the roles of multiple stereotypes in the relationship between consumers and service providers.
... Satisfaction according to Felix (2017) can be defined as "If you expect a certain level of service, and perceive the service reviewed to be higher, you are a satisfied client [18]. Huetten et al. [19] however recommended to facilitate patient satisfaction is an optimistic affecting reaction that is required from cognitive procedure in which patient compare their individual experience to the set of subjective standards. ...
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Aims: To evaluate patients’ level of satisfaction on the quality of healthcare received by focusing on waiting time due to its level of importance. Studies have shown that a good healthcare system contributes immensely to the growth of a thriving economy, because patients’ satisfaction is the major indicator of quality healthcare. Study Design: A descriptive cross-sectional study was employed by using a structured questionnaire coupled with interview session. These was considered appropriate for data gathering in the overall outpatient department (OPD) of the health facility. Methods: The present study evaluates patients’ satisfaction level on the QoS in Ekiti State University Teaching Hospital (EKSUTH), Nigeria; by focusing majorly on waiting time. Systematic random sampling technique was used in selecting the participants for this research, with 241 patients’ data collected. Convenience, courtesy and quality of care were used as factors to measure patients’ satisfactions. Results: Findings from this study showed that 73.03% of the patients were satisfied with the level of services in terms of conveniences, while 80.50% of the patients were highly satisfied as regards the courtesy level, also, 77.59% of the patients were satisfied with the quality of care received at the facility. Furthermore, our result indicates that a total of 154 (63.9%) of the patients were greatly satisfied with the quality of health services received in EKSUTH, however, 87 which represents 36.1% of patients were not satisfied with the level of services rendered at the facility. Conclusion: The respondents showed high satisfaction level in most of the services they received from EKSUTH, however, long waiting time in the health facility has shown to be an impediment to the satisfaction level as well as the quality of care (QoC) received. Therefore, improved services; especially reducing the long waiting time will motivate patients to continue to utilize EKSUTH. More so, continuous efforts should be made by the hospital’s administration to improve other areas where satisfaction level was shown to be low in the present study.
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Purpose This study investigates the role of personal resource (i.e. psychological empowerment) in reducing the negative impact of emotional exhaustion of frontline employees on their engagement. It also examines the moderating effects of ethical climate and transformational leadership in mitigating the negative influence of emotional exhaustion on engagement among frontline service employees (FLEs). Design/methodology/approach Data were collected from 671 frontline employees from financial services sector. Confirmatory factor analysis (CFA) and hierarchical regression analysis (HRA) were used to test the hypothesized relationships. Findings Results show that the impact of emotional exhaustion on employee engagement is greatly affected by psychological empowerment. Transformational leadership moderates the negative effects of emotional exhaustion on psychological empowerment, while ethical climate weakens the negative impact of emotional exhaustion on employee engagement. Practical implications Service firms need to provide enough autonomy to emotionally exhausted frontline employees so that they feel valued. The emotionally exhausted employees can be engaged if they are empowered to discharge their job most effectively and a climate is ensured which can keep them motivated toward accomplishing their targets. A fair and just treatment shall boost their morale to perform better and to strengthen their staying intentions. Originality/value The novelty of our study lies in examining and fostering engagement among emotionally exhausted FLEs. It shows that job resources at the individual level (i.e. psychological empowerment), team level (i.e. transformational leadership) and organizational level (i.e. ethical climate) can help in encouraging work engagement among emotionally exhausted FLEs.
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