Abstract
Objective To examine patients’ experiences of fairness and commitment in the health care context with an emphasis on primary care providers.
Design Qualitative, semistructured, individual interviews were used to gather evidence for the justice and commitment frameworks across a variety of settings with an emphasis on primary care relationships.
Setting Rural, urban, and semiurban communities in Nova Scotia.
Participants Patients (ages ranged from 19 to 80 years) with varying health care needs and views on their health care providers.
Methods Participants were recruited through a variety of means, including posters in practice settings and communication with administrative staff in clinics. Individual interviews were conducted and were audiotaped and transcribed verbatim. A modified grounded theory approach was used to interpret the data.
Main findings Current conceptualizations of justice (distributive, procedural, interpersonal, informational) and commitment (affective, normative, continuance) capture important elements of patient–health care provider interactions and relationships.
Conclusion Justice and commitment frameworks developed in other contexts encompass important dimensions of the patient–health care provider relationship with some exceptions. For example, commonly understood subcomponents of justice (eg, procedural consistency) might require modification to apply fully to patient–health care provider relationships. Moreover, the results suggest that factors outside the patient–health care provider dyad (eg, familial connections) might also influence the patient’s commitment to his or her health care provider.
A large body of research in the work organization domain supports the conclusion that perceptions of fairness are a primary determinant of relationship quality, including assessments of trust in decision makers.1,2 Moreover, fairness perceptions are associated with the level and nature of people’s attachments or commitments to entities.1–4 Indeed, thinking that one is fairly treated tends to produce commitments based on identification and feelings of emotional attachment to the entity (eg, one’s supervisor). In turn, fairness perceptions1,2,5,6 and positive forms of commitment3,4 relate to a multitude of positive outcomes, including greater employee well-being and adherence to organizational policies.
We extend these lines of research via qualitative interviews to consider patients’ experiences of fairness and commitment in the health care context with an emphasis on patients’ interactions with primary care providers. Indeed, a full understanding of outcomes, such as trust and treatment adherence, might require an understanding of the influence of these constructs. With a few exceptions (eg, work by Fondacaro et al,7 and Hughes and Larson8), little research has examined these constructs in patient–health care provider encounters and relationships.
Fairness and commitment
Research by Gutek and colleagues, which examines interactions between customers and broadly defined service providers, suggests that having someone whom patients can refer to as my doctor (versus, for example, having encounters with different providers each time a medical need arises) leads to greater satisfaction with services, greater trust in the provider, and increased frequency of service interactions.9–11 However, studies in the psychology and management literatures on organizational commitment suggest that simply remaining with or being committed to an entity does not necessarily translate into positive outcomes.3,4 Indeed, people might remain with an entity (eg, their organization) because they have to, perhaps owing to a lack of available alternatives or high personal costs associated with leaving (termed continuance commitment); because they believe they have an obligation to, perhaps out of a sense of loyalty to the entity and feelings of guilt that arise at the thought of leaving (termed normative commitment); because they truly want to, perhaps because they truly like and identify with the entity (termed affective commitment); or because of some combination of these motives.3,4 Affective commitment to entities is more strongly related to positive outcomes (eg, employee well-being, compliance with rules and procedures) than the other bases of commitment.4
With respect to building affective commitment within organizations, people’s perceptions of fairness play a key role.1–4 Assessments of fairness at work stem from people’s evaluations of at least 4 primary elements.1,5 Distributive justice reflects people’s assessments of the fairness of the outcomes they receive.5,12 Procedural justice reflects an assessment of the fairness of the procedures used to allocate outcomes or make decisions.13,14 For example, to be fair, procedures should be based on accurate information, minimize the influence of personal biases, and uphold ethical and moral principles.13 Interactional justice reflects the quality of interpersonal treatment individuals receive from decision makers and is subdivided further into interpersonal justice, reflecting judgments about the dignity and respect shown by decision makers, and informational justice, reflecting the adequacy of the information and explanations provided by decision-making agents.5,15 Greater justice perceptions have been shown to positively predict numerous outcomes, including affective commitment to entities1–4 and trust in decision makers.1,2
In the current study, we used qualitative interviews to gather evidence for these theoretical frameworks across a variety of settings with an emphasis on primary care relationships (eg, patients’ relationships with their family doctors).
METHODS
Participants
Ethics approval for the study was obtained before commencing the research. Participants (8 men, 15 women) were recruited through a variety of means, including posters in practice settings and communication with administrative staff in clinics. We used criterion sampling16 to recruit participants. Specifically, to ensure a diverse sample, we sought participants who had a range of opinions on their health care providers and who had a range of clinical needs. We included participants from across the age spectrum (19 to 80 years of age) who resided in rural, semiurban, or urban communities, and who used a variety of avenues (eg, walk-in clinics, family doctors, emergency departments) to access medical care. These selection criteria were used to capture potential diversity in patients’ experiences of fairness and commitment as a function of demographic and setting variables. In total, 23 individual interviews were conducted between May 2006 and March 2007.
Data collection
The individual (semistructured) interviews were conducted by the first 2 authors (C.H. and P.T.) and were audiotaped and transcribed verbatim. Private, individual interviews were chosen because they allowed participants to express their opinions about their relationships with their health care providers frankly and confidentially. A basic interview guide was followed; questions pertaining to the nature and quality of patients’ relationships with their health care providers were posed. Interviews were approximately 45 minutes long, though they ranged between about 30 and 60 minutes.
Coding and analysis
The analysis was guided by modified grounded theory methods, which sought to develop and understand connections between and among analytical categories.17–19 Transcripts were read independently by 2 members of the research team (C.H. and P.T.), who searched for examples of justice and commitment, and who identified additional passages for further consideration. Emerging ideas were compared and contrasted and then linked to the justice and commitment categories that were known through the literature. Disagreements were resolved through team discussion, and an open-coding strategy was also used to accommodate other findings. Through this strategy, data were coded using QSR N6, a software program designed for textual analysis. Reports were generated for each code, permitting the research team to confirm or qualify the coding structure, as well as to ensure it continued to accommodate the data. Such an approach is well suited for examining multiple perspectives on a complex issue, such as the nature of relationships between health care providers and patients. Our main focus in this paper is to present thematic categories that illuminate constructs of justice and commitment from our interviews.
RESULTS
Overall, findings suggest that current conceptualizations of justice and commitment capture important elements of health care interactions and relationships. Tables 15,12–15 and 23,4 present definitions adapted (by the authors) to the health care context and representative interview quotes of the key justice and commitment constructs.
Justice constructs and illustrative quotes
Commitment constructs and illustrative quotes
Based on past research,7 we conceptualized distributive justice in terms of need-based principles (wherein outcomes or resources are allocated based on individual need). This distributive justice principle is in contrast to equality-based allocations (wherein all individuals receive the same outcomes or resources regardless of need or inputs) or equity-based allocations (wherein outcomes are allocated according to individual contributions or inputs).12 Findings relating to the fairness of need-based outcome allocations tapped many domains, including wait times for appointments, referrals to specialists, and resolutions to medical issues.
Evidence for most of the procedural justice components was also noted. For example, procedural accuracy was reflected in statements regarding the thoroughness of the doctors’ procedures to diagnose issues, including referrals to specialists when necessary. Concerns related to bias suppression were evident, for example, in statements regarding providers’ attitudes concerning participants’ ethnocultural backgrounds or sexual orientations. Correctability was evident in statements reflecting the participants’ abilities to change treatment pathways because of ineffectiveness or lack of suitability. Voice or representativeness concerns were evident in statements regarding the providers’ willingness to listen to patients’ concerns regarding their care or conditions. The notion of procedural consistency over time and across patients was less evident; rather, consistency emerged as a concern through the concepts of continuity of care and coordination among health care providers. Finally, the procedural justice construct of ethicality appeared less applicable to the one-on-one patient–health care provider interactions that were the focus of the current research; no interview quotes were coded with this label.
The concept of interpersonal justice was also evident in patients’ discourse about their health care interactions and relationships. For example, statements regarding the level of sensitivity, dignity, and respect afforded the patient were made. Informational justice was also evident not only in terms of the provision of explanations for courses of action and treatments, but also in terms of information about one’s condition and educational information (eg, how to read food labels for diabetes care).
With respect to patient commitment to providers, all 3 types of commitment were evident within the patient interviews.3,4 That is, patients articulated the decision to remain with their health care providers using all of the known commitment constructs: having a true identification with and liking of their providers (ie, affective commitment); acknowledging a lack of alternatives or a loss of investments that would accrue if they left their providers (ie, continuance commitment); or believing they had an obligation to remain with their health care providers (ie, normative commitment). Interestingly, a potential additional subcomponent of normative commitment was identified. Some patients expressed remaining with health care providers not necessarily because of a sense of obligation to their providers, but rather because of a sense of obligation toward family members who seek care from the same provider and whose care might be disrupted if the patient switched providers.
DISCUSSION
Analyzing health care relationships and interactions in terms of justice perceptions appears to be a viable approach. However, some justice constructs might need refinement to provide a better fit to this health care context. For example, the notion of procedural consistency might need to be broadened to include issues of continuity of care and coordination among health care professionals; these concerns were evident in patient discourse surrounding their health care interactions. Consistency in decision making across patients, however, did not emerge; it might be somewhat difficult for patients to assess consistency across their providers’ patients, making this concern less salient. However, this concern might be seen in broader statements with respect to preferential access to medical treatment (eg, magnetic resonance imaging) for certain groups (eg, athletes). Ethicality also did not emerge as a concern in patient discourse. Similarly, it might be that broader judgments about the health care system are more susceptible to concerns about ethical treatment (eg, long wait times to see specialists and to be seen in emergency departments).
In the context of clinical care, aspects of voice and interpersonal justice might also become somewhat indistinguishable. In the primary care context, procedural justice and interpersonal justice are often (although perhaps not always) tied to the same person—the primary care provider. In this sense, justice type and justice source are nested in the same relationship, possibly muddying the distinction between the elements of justice.20 This finding might be highly contextual and there are likely other aspects of clinical care in which these 2 justice domains are more sharply differentiated.
With respect to discourse surrounding bases of commitment, our data suggest that patients might remain with providers because they are attached to and genuinely like them (affective commitment); they think they have no other choice in health care providers or their care would be disrupted if they left (continuance commitment); or they believe they ought to be loyal to their health care providers and would feel guilty if they left (normative commitment).3,4 Interestingly, some patients also reported staying with their health care providers owing to, in part, a felt obligation to their family members who see the same provider and whose care might be interrupted if the patient left. Thus, while commitment in clinical care is typically thought to be based on the provider-patient dyad, there are times when other networks shape the relationship. In our data, this was most clearly expressed when the same provider rendered care to parent and child. Familial connections, then, might foster normative commitment to providers. Future research could investigate other relationships or networks outside of the family (eg, close friends, coworkers, others who share an illness or disease experience) that might influence patients’ commitment to their health care providers.
Limitations
Our data do not speak to the causal relationships among judgments of fairness, bases of commitment, and other important outcomes (eg, patient satisfaction, trust, treatment adherence). Thus, in future quantitative research, we encourage researchers to validate self-report measures of the justice and commitment constructs tailored to health care interactions and relationships. Subsequently, researchers could use a longitudinal design to examine consequences of perceptions of justice and bases of commitment in terms of patient outcomes such as satisfaction and health behaviour (eg, following recommendations, reporting ineffective treatments). Although not the specific focus of the current research, future research might also seek to understand patients’ judgments of fairness with respect to the broader health care system outside of their relationships with their primary care providers. For example, research might seek to uncover patients’ views concerning the fairness of the distribution of health care resources and spending in Canada. Moreover, judgments of the fairness of the procedures used to allocate health care spending and set health care priorities could be assessed. In addition, research might assess patients’ views pertaining to the adequacy and timeliness of information sharing with respect to broader health care decisions, priorities, and initiatives.
Conclusion
Further research on perceptions of fairness and bases of commitment might help clarify aspects of patient–health care provider relationships and interactions that are not captured in current health care literature (eg, studies on communication). These constructs might be important for understanding the quality and outcomes of patient-doctor relationships, including assessments of trust and satisfaction, and behaviour such as treatment adherence. Indeed, understanding what factors facilitate such positive outcomes is of paramount importance to the effective functioning of the health care system. We suggest that investigations applying research and theory in social and organizational psychology—including further studies applying the constructs of justice and commitment—might shed new light on important outcomes of patient–health care provider relationships.
Acknowledgments
We would like to thank the Nova Scotia Health Research Foundation for providing funding (a research grant awarded to all authors) to support this project. Portions of the work have been presented at conferences (eg, the Canadian Psychological Association Annual Convention) and via academic talks (eg, at Dalhousie University in Halifax). We would also like to thank the research assistants who worked on this project, especially Adriana Hess and Pam Corell.
Notes
EDITOR’S KEY POINTS
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Having someone whom patients can refer to as my doctor (as opposed to, for example, having encounters with different providers each time a medical need arises) leads to greater satisfaction with services, greater trust in the provider, and increased frequency of service interactions.
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Findings suggest that current conceptualizations of justice and commitment capture important elements of health care interactions and relationships.
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With respect to discourse surrounding bases of commitment, data suggest that patients might remain with providers because they are attached to and genuinely like their providers (affective commitment); they think they have no other choice in health care providers or their care would be disrupted if they left (continuance commitment); or they believe they ought to be loyal to their health care providers and they would feel guilty if they left (normative commitment). A patient might also remain because of a sense of obligation toward family members who seek care from the same provider and whose care might be disrupted should the patient switch providers.
POINTS DE REPÈRE DU RÉDACTEUR
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Le fait d’avoir quelqu’un auquel le patient peut s’adresser comme à son médecin (par opposition au fait, p. ex. d’avoir affaire avec des soignants différents chaque fois qu’il survient un problème médical) entraîne une plus grande satisfaction envers les services, une meilleure confiance envers le soignant et des interactions plus fréquentes entre les services.
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Nos observations donnent à croire que la façon actuelle de concevoir la justice et l’engagement s’applique en grande partie aux interactions et interrelations associées aux soins de santé.
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Quant aux opinions sur les bases de l’engagement, nos données laissent voir que les patients pourraient conserver le même soignant parce qu’ils lui sont attachés et qu’ils lui ressemblent vraiment (engagement affectif); parce qu’ils croient ne pas avoir d’autre choix de soignant ou que leurs soins manqueraient de continuité s’ils en changeaient (engagement de continuité); ou parce qu’ils se sentent obligés d’être loyaux envers leur soignant et qu’ils se sentiraient coupables de l’abandonner (engagement normatif). Un patient pourrait aussi conserver le même soignant à cause d’un sentiment d’obligation envers les membres de sa famille qui sont soignés par la même personne et dont les soins pourraient être perturbés advenant que le patient opte pour un autre soignant.
Footnotes
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This article has been peer reviewed
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Cet article a fait l’objet d’une révision par des pairs.
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Contributors
All authors were instrumental in obtaining funding to support the project and contributed to the design and write-up of the manuscript. Drs Holmvall and Twohig conducted the interviews reported herein and conducted the initial data analysis, interpretation, and write-up of the current manuscript. This manuscript in its entirety was subsequently reviewed and edited for intellectual content by the remaining authors.
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Competing interests
None declared
- Copyright© the College of Family Physicians of Canada
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