How to enhance citizenship and reduce dysfunctional patient behavior during service interactions: An empirical study in the nursing context

Publication Type

Contribution to conference

Authors

Schmitz, G., Lerch, J., Büttgen, M., & Ates, Z.

Year of publication

2016

Published in

Conference Proceedings AMA SERVSIG 2016

Page (from - to)

353-359

Conference name

AMA SERVSIG

Conference location

Maastricht, Netherlands

Conference date

June 17th - 19th, 2016

Abstract

Introduction

Patients are widely acknowledged as indispensable co-creators of value in the healthcare context. Accordingly, the examination of different types, drivers and outcomes of patients’ value co-creation activities has emerged as key service research priority. Thereby, most prior research on value co-creation has been conducted in specific health care contexts. Surprisingly, research concerning value co-creation behaviors of inpatients in the clinic context as one specific and important health care context is relatively sparse (Sweeney et al. (2015)). Moreover, studies focus on mandatory inpatient participation behaviors during the health care service encounter with physicians as one specific category of value co-creation behavior (Gallan et al. (2013)).

As research concerning different types of value co-creation behaviors in other specific health care contexts has shown, patients do not only show mandatory, but also different kinds of voluntary behaviors (McColl-Kennedy et al. (2012); Sweeney et al. (2015); Verleye et al. (2014)). Thus, inpatients may also perform different kinds of such extra-role citizenship behaviors benefiting the service provider in some way. On the contrary, research in professional service contexts demonstrates that co-creation behavior of customers may not always be effective (Greer (2015)). Therefore, dysfunctional patient behavior, defined as any patient behavior that obstructs the service provider from co-creating value, may also be an issue in the clinic context, where patients are in an anxiety-producing situation in which they are confronted with uncertainty and risk (Berry/Bendapudi (2007); Gallan et al. (2013)). Thus, the emotional state of inpatients is assumed to have a potential critical influence on the dysfunctional as well as on the citizenship behavior (Yi/Gong (2008)). Moreover, patient citizenship and dysfunctional behaviors may emerge in different forms and can also occur simultaneously (Garma/Bove (2011); Yi/Gong (2013)).

In the clinic context, inpatients may show these forms of behavior especially during service interactions with nurses due to the nature, duration and intensity of the interpersonal relationship between patients and nurses. The role of the nurse as health care provider differs from the role of physicians: Nurses see fewer patients and spend more time with each patient (Crossan/Robb (1998)). Thus, they seem to be able to develop closer interpersonal relationships based on communication (Seiders et al. (2015)) and observable actions (Bettencourt/Brown (1997); Martinez-Gonzalez et al. (2014)), which may have an impact on patient citizenship as well as dysfunctional behaviors.

Notwithstanding the widespread occurrence of dysfunctional and citizenship behavior of patients, there is a lack of research concerning these extreme forms of inpatient participation behavior towards the nurse during service interactions. Due to this research gap, little is known about the different forms and outcomes of citizenship and dysfunctional patient behavior as well as about opportunities for nurses to influence these different forms of patient behavior during service interactions.

 

Contribution

The purpose of this study is to explore how and why inpatients participate in citizenship and dysfunctional behavior during service interactions with nurses and to assess effects of these behaviors on perceived service quality. We contribute to research on patient citizenship and dysfunctional behavior in health care services during service interaction with nurses by (1) identifying different forms of patient citizenship and dysfunctional behaviors during service interactions with nurses; (2) demonstrating direct as well as indirect effects – emerging through positive and negative patient emotions - of the perceived interpersonal relationship on different forms of interactive patient citizenship and dysfunctional behaviors; (3) showing, how different forms of interactive patient citizenship and dysfunctional behaviors influence perceived service quality and (4) providing empirical evidence that patients´ perceptions of the communication and interactive citizenship behavior of nurses affect the interpersonal relationship.

 

Study 1: Exploratory analysis of interactive patient citizenship and dysfunctional behavior

To identify the different forms of interactive patient citizenship and dysfunctional behavior we started with a literature review and conducted a qualitative study in four hospitals comprising 17 interviews with inpatients and 26 nurses. To ensure a comprehensive analysis, all interviews were recorded and transcribed. The analysis followed a combination of conventional content analysis and directed content analysis (Hsieh/Shannon (2005); Mayring (2000)) using the qualitative data analysis software MAXQDA 11. Based on previous research concerning different forms of customer citizenship (Garma/Bove (2011)) and dysfunctional behavior (Greer (2015)), we found support for the following six forms of interactive patient citizenship and five forms of interactive dysfunctional patient behavior:

 

 

Interactive Patient Citizenship Behavior (IPCB)

1)    Support through direct actions

2)    Support through information

3)    Support through patience and understanding

4)    Support through positive word of mouth

5)    Support through individual encouragement

6)    Support through personal appreciation

 

Interactive Dysfunctional Patient Behavior (IDPB)

1)    Refusal to cooperate

2)    Verbal abuse

3)    Negative word of mouth

4)    Physical aggression

5)    Sexual harassment

 

Conceptual framework

Drawing on social exchange theory and affect theory of social exchange, we provide a framework and hypotheses about the antecedents and effects of the interpersonal relationship on the different forms of interactive patient citizenship and dysfunctional behaviors. Social exchange theory states that social exchange involves a series of interactions that generate obligations (Emerson (1976)). These interactions are usually seen as interdependent and contingent on the actions of another person (Blau (1964)). In this context, the best known underlying exchange rule is the expectation of reciprocity (Cropanzano/Mitchell (2005)). Thus, we assume that patients´ perceptions of the interpersonal relationship will have a direct positive/negative effect on the different forms of interactive patient citizenship/dysfunctional behaviors. Moreover, we propose that patient perceived communication as well as the perceived citizenship behavior of nurses will have a positive effect on the interpersonal relationship. According to affect theory of social exchange, exchange outcomes produce positive or negative feelings (Lawler (2001)). Therefore, we hypothesize that the interpersonal relationship has a positive/negative influence on positive/negative emotions. Moreover, affect theory of social exchange holds that social exchanges are driven by emotions. Thus, we assume that patients´ positive/negative emotions have an influence on the different forms of patient citizenship and dysfunctional behaviors. This means that the relationship effects on the different forms of interactive patient citizenship and dysfunctional behavior will be mediated by positive and negative emotions. Finally, in accordance with previous research concerning the outcomes of citizenship/dysfunctional behaviors in other service contexts (Yi/Gong (2006)), we propose that the different forms will increase/decrease perceived service quality.

 

Study 2: Methodology and Findings

In order to test the hypotheses we conducted a quantitative study using a standardized questionnaire. Based on the literature review and the qualitative study, established scales for the measurement of the constructs were identified, adjusted for the context or new scales were developed. We gathered data in four hospitals. 929 patients staying in hospital were asked to participate in the study. It was emphasized that the participation was voluntary and anonymous and that the data was analyzed by extern researches. In total, 456 patients participated (response rate of 49 %) and 404 questionnaires were usable for the analysis. 51% of the respondents were male. Further approximately 6% were younger than 30 years, 25% between 30 and 49 years, 43% between 50 and 70 years and 24% over 70 years.

We used Partial Least Squares (PLS) to evaluate the measures and to estimate the structural equation model. The measures employed in our study performed well as the values of the established psychometric criteria exceed the standards given in literature. The structural model was tested for each form of the identified citizenship and dysfunctional behaviors (see for a similar model and hypotheses testing Verleye et al. (2014)).

Results reveal that the interpersonal relationship is a strong predictor for patient citizenship behaviors, as we found a positive direct effect on all six identified forms. On the contrary, the perceived interpersonal relationship is less important concerning dysfunctional patient behaviors, as it only has a direct effect on negative word of mouth and thus on one identified form. Additionally, the interpersonal relationship has a positive influence on patients´ positive emotions and a negative influence on patient´s negative emotions. Furthermore, patients´ positive emotions have a positive influence only on three of the six forms of patient citizenship behavior. Therefore, the perceived interpersonal relationship doesn´t show indirect effects on all forms of IPCB. On the contrary, all six forms of IDPB are influenced by negative emotions, whereby the interpersonal relationship has an indirect effect through negative emotions. Furthermore, all six forms of IPCB have a positive effect on patient perceived service quality, whereas the different forms of IDPB do not have an impact on patient perceived service quality. Finally, perceived communication and interactive nurse citizenship behavior are strong predictors for the perceived interpersonal relationship.

 

Conclusion

Our results strengthen the high relevance of positive interpersonal relationships for interactive citizenship behaviors of inpatients: Nurses are able to stimulate patient citizenship behavior directly, which in turn has an impact on perceived service quality. On the contrary, the interpersonal relationship provides lesser chances to influence interactive dysfunctional behavior of inpatients. Summarizing, this study shows that various opportunities exist to encourage patient citizenship behaviors in service interactions, while preventing dysfunctional customer behaviors is a big challenge for nurses. This leads to several implications for the management of service interactions in the nursing context, which will be shown in the presentation. For example, in order to establish strong interpersonal relationships, nurses need to have special abilities and motivations as well as enough time for communication and interactive citizenship behavior.

 

 

 

 

References

Berry, L.L.; Bendapudi, N. (2007): Health Care: A Fertile Field for Service Research. In: Journal of Service Research, Vol. 10 (2): 111-122.

Bettencourt, L.A.; Brown, S.W. (1997): Contact employess: Relationships among workplace fairness, job satisfaction and prosocial service behaviors. In: Journal of Retailing, Vol. 73: 39-61.

Blau, P.M. (1964): Exchange and power in social life. New York: John Wiley.

Cropanzano, R.; Mitchell, M.S. (2005): Social Exchange Theory: An Interdisciplinary Review. In: Journal of Management, Vol. 31 (6): 874-900.

Crossan, F.; Robb, A. (1998): Role of the nurse: introducing theories and concepts. In: British Journal of Nursing, Vol. 7 (10): 608-612.

Emerson, R:M. (1976): Social exchange theory. In: Annual Review of Sociology, Vol. 2: 335-362.

Gallan, A.S.; Jarvis, C.B.; Brown, S.W.; Bitner, M.J. (2013): Customer positivity and participation in services: an empirical test in a health care context. In: Journal of the Academy of Marketing Science, Vol. 41: 338-356.

Garma, R.; Bove, L.L. (2011): Contributing to well-being: customer citizenship behaviors directed to service personell. In: Journal of Strategic Marketing, Vol. 19 (7): 633-649.

Greer, D.A. (2015): Defective co-creation: Developing a typology of consumer dysfunction in professional services. In: European Journal of Marketing, Vol. 49 (1/2): 238-261.

Hsieh, H.-F.; Shannon, S.E. (2005): Three approaches to qualitative content analysis. In: Qualitative Health Research, Vol. 15 (9): 1277-1288.

Lawler, E.J. (2001): An Affect Theory of Social Exchange. In: American Journal of Sociology, Vol. 107 (2): 321-352.

Martinez-Gonzalez, N.A.; Djalali, S.; Tandjung, R.; Huber-Geismann, F.; Markun, S.; Wensing, M.; Rosemann, T. (2014): Substitution of physicians by nurses in primary care: a systematic review and meta-analysis. In: BMC Health Services Research, Vol. 14: 214-231.

Mayring, P. (2000): Qualitative Content Analysis. In: Forum Qualitative Social Research, Vol. 1 (2), Art. 20, http://nbn-resolving.de/urn:nbn:de:0114-fqs0002204.

McColl-Kennedy, J.R.; Vargo, S.L.; Dagger, T.S.; Sweeney, J.C.; van Kasteren, Y. (2012): Health Care Customer Value Cocreation Practice Styles. In: Journal of Service Research, Vol. 15 (4): 370-389.

Seiders, K.; Flynn, A.G.; Berry, L.L.; Haws, K.L. (2015): Motivating Customers to Adhere to Expert Advice in Professional Services. A Medical Service Context. In: Journal of Service Research, 18 (1): 39-58.

Sweeney, J.C.; Danaher, T. S.; McColl-Kennedy J.R. (2015): Customer Effort in Value Cocreation Activities: Improving Quality of Life and Behavioral Intentions of Health Care Customers. In: Journal of Service Research, Vol. 10 (9): 21-28.

Verleye, K.; Gemmel, P.; Rangarajan, D. (2014): Managing Engagement Behaviors in a Network of Customers and Stakeholders: Evidence From the Nursing Home Sector. In: Journal of Service Research, Vol. 17 (1): 68-84.

Yi, Y.; Gong, T. (2006): The Antecedents and Consequences of Service Customer Citizenship and Badness Behavior. In: Seoul Journal of Business, Vol. 12 (2): 145-176.

Yi, Y.; Gong, T. (2008): The effects of customer justice perception and affect on customer citizenship behavior and customer dysfunctional behavior. In: Industrial Marketing Management, Vol. 37: 767-783.

Yi, Y.; Gong, T. (2013): Customer value co-creation behavior: Scale development and validation. In: Journal of Business Research, Vol. 66: 1279-1284.