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Abstract

As life has become noticeably more comfortable compared to the past, there is a mounting interest in various service sectors, such as healthcare, where growing demand has led to an increase in the number facilities that supply products essential to service provision. Enhancing the service quality is critical to gaining an advantage in the fiercely competitive healthcare environment and is especially important as the outcomes encompass not only the treatment of disease but also patients’ emotional and experiential satisfaction. This study presents procedural justice and two dimensions of trust as factors related to physician and patient relationship, investigating their effects on patients’ intention to continue the relationship with their healthcare providers. We found that procedural justice had a positive effect on the two dimensions of trust, and the latter had a significant positive effect on the continuity intention. As this study verifies the necessity of procedural justice and trust for patients to continuously experience medical services, it is imperative for the healthcare industry to understand and incorporate these factors into their practices.

Keywords

procedural justice cognitive trust emotional trust intention of continuous relationship healthcare management

What do we already know about this topic?

How does your research contribute to the field?

This study presents procedural justice and two dimensions of trust as factors related to physician and patient relationship, investigating their effects on patients’ intention to continue the relationship with their healthcare providers.

What are your research’s implications toward theory, practice, or policy?

This study is significant in that it highlighted the significance of trust, in addition to patient satisfaction, for healthcare facilities to thrive in a competitive business environment.

Introduction

In contemporary society, life has become noticeably more comfortable compared to the past, and the quality of life has improved markedly. Consequently, there is a mounting interest in various service sectors, with healthcare services standing out as a prime example. This heightened importance can be attributed to the shifting societal factors such as an aging population and increased education levels. With growing demands for healthcare services, healthcare and non-healthcare facilities that supply products essential for providing healthcare services have surged.¹ Hence, numerous advanced nations, including the United States, are experiencing progression in the healthcare-related industries and professions, further highlighting the importance of healthcare services.

Healthcare services refer to direct or indirect amenities for managing illnesses; they differ from other services in that they have evolved into specialized and scientific fields. Their quality is multifaceted, defined through the perspectives of various stakeholders, including physicians and patients. They generally encompass the treatment of medical conditions and address the emotional aspects experienced by patients during the process.² Enhancing the quality of healthcare services becomes a strategic advantage in an increasingly competitive landscape.

In essence, healthcare service industry extends beyond the management and treatment of diseases, encompassing the patients’ emotional and experiential satisfaction as outcomes of these facilities. Therefore, delivering high-quality services is paramount to enhancing the performance of healthcare institutions. Thus, there are active quantitative and qualitative studies aimed at improving the healthcare services’ quality and processes through various methodologies. Specifically, Tyler and Allan Lind³ emphasizes the importance of procedural justice in explaining why individuals comply with norms within an organization. Procedural justice arises when people believe that decisions are made through fair procedures, which in turn enhances their trust and satisfaction with the organization. In other words, organizational justice and procedural justice are interconnected, with organizational justice encompassing the fair and transparent execution of all procedures within the organization. However, a research from a comprehensive standpoint, covering the entire spectrum of healthcare services, consumer perceptions, and ultimate satisfaction, is unavailable. Thus, this study aimed to chart a path toward consumer-oriented healthcare by examining procedural justice and the two dimensions of trust as factors related to the physician-patient relationship.

Justice is currently a prominent theme across various sectors. It has gained substantial research interest in the healthcare sector as well, presumably driven by the inherent complexities arising from the differing perspectives between physicians and patients. In particular, Prusiński⁴ found that procedural fairness between patients and healthcare providers significantly enhances trust, improves treatment effectiveness, and increases patient satisfaction. In addition, Fleurbaey and Schokkaert⁵ found that inequality and unfairness in the healthcare industry are caused by a variety of factors, including social background, lifestyle, etc. In other words, fair procedures are important in many industries, but they are especially important in the healthcare industry, where human lives are at stake, and procedural fairness should be ensured in healthcare settings. For instance, South Korea recently enacted a legislation mandating the installation of security cameras in operating rooms. While physicians may perceive this as encroaching on their fundamental rights, patients consider the service or outcomes and transparency throughout the healthcare process essential, which warrants such legislative measures.

Hence, this study delved into the importance of procedural justice within the relationship between healthcare service providers and customers and explored the significance of the two dimensions of trust. Furthermore, it investigated how these elements impact the intention of continuous relationships that can be regarded as an outcome of these factors. Studying the effects of procedural justice practiced by physicians on their patients’ cognitive trust, affective trust, and the intention of continuous relationships will highlight the measures to effectively navigate the evolving markets and enhance the service quality. Based on the above literature, this study adopts fairness theory because the relationship between healthcare providers and customers is an important interpersonal relationship with psychological implications. In particular, consumers form trust based on fair procedures, which we believe will provide academic and practical insights in today’s healthcare industry where unethical behavior is prevalent. Thus, this research’s objectives can be summarized as follows:

- Assess the effects of procedural justice on cognitive trust, affective trust, and the intention of continuous relationship.

- Recognize the significance of procedural justice within the healthcare research.

- Underscore the need for the two dimensions of trust in physician-patient relationships.

Theoretical Background

Organizational and Procedural Justice

Literally, fairness implies a harmony between outcomes and processes. According to behavioral science, individuals tend to assess justice through a process of comparing the treatment and rewards they receive with that of the others, rather than simply viewing the latter per se. Specifically, Mentovich et al⁶ noted the importance of having a personal voice, which not only fulfills human needs but also plays a critical role in maintaining and enhancing freedom and self-determination. Expanding this concept from individuals to organizations, justice can be subdivided into various forms. First, the establishment of organizational justice motivates organizational members, and establishing procedural justice, a factor of organizational justice, ensures the transparency of processes through the systematization of work processes. Specifically, organizational justice, including procedural justice, has been given significance and researched from various perspectives because it generates tangible and intangible outcomes by ensuring transparency of both outcomes and processes within an organization.

The discussion of organizational justice originated from the research by Adams.⁷ It refers to fairness in rewards within an organization. Organizational members evaluate how they are treated within their organization and compare it to the treatment of other members. If individuals perceive that an organization provides fair treatment to themselves and others, this perception can serve as another means of motivation beyond financial rewards.^8,9 Furthermore, it not only motivates individuals, but also bestows a positive attitude toward the organization, contributing to the overall organizational performance.

However, there were limitations in explaining the process of justice within the broad framework of organizational justice. Thus, procedural justice emerged to discuss the justice of an organization regarding systems, plans, and procedures.¹⁰ It focuses on the fairness of the processes and rules implemented until the outcomes have been achieved. Hence, procedural justice emphasizes how decisions are made as well as the procedures through which individuals achieve results.¹¹

Cognitive and Affective Trust

To efficiently achieve our goals, we form transactional relationships with partners with the capabilities needed to attain those objectives. Furthermore, the parties of a partnership anticipate mutual benefits and the tangible performance of each organization. In such situations, the parties of a partnership develop various forms of trust, notably cognitive and affective trust.

Cognitive trust reflects the degree to which one believes that the partner possesses the competencies to effectively perform their assigned tasks and achieve the intended objectives.¹² Specifically, the trust formed through objectively proven data or accumulated results can be defined as cognitive trust; it is a required component for service operations and partnership formation.^13,14 Building cognitive trust requires expertise, professionalism, and unique knowledge, and its maturation leads to the exchange of competencies and the realization of anticipated outcomes.

However, affective trust signifies the trust formed based on emotions experienced within organizational and service relationships. Unlike cognitive trust, which relies on the partner’s competencies, it is rooted in subjective characteristics measured through experiences. Specifically, while cognitive trust is based on rationality, affective trust is based on emotions and experiences. While it may not be grounded in rational data, affective trust plays a crucial role in reducing uncertainty about one another and fostering positive emotions, rendering it as an equally important factor as cognitive trust.¹⁵

This trust also plays an important role in the healthcare industry. In particular, building trust between healthcare providers and patients is of paramount importance, with Zein et al¹⁶ exploring the importance of fairness and trust in the acceptance of social insurance policies in Indonesia, and Lee¹ empirically analyzing how cognitive trust in the physician-patient relationship improves patient satisfaction. In a similar vein, Prusiński¹⁷ studied physician authenticity in patients’ treatment decisions and found that trust in the healthcare organization and the authenticity shown by the physician to the patient positively influenced patients’ intention to continue treatment. In other words, it can be interpreted that the emotional connection between the healthcare provider and the patient and the trust in the healthcare provider’s professionalism, knowledge, and competence can increase patient satisfaction and quality of healthcare services.

Intention of a Continuous Relationship

The intention of a continuous relationship can be defined as the purpose to continue long-term transactions that arise from the combination of the service provider’s product, service satisfaction, and marketing elements. It manifests through accumulated experiences, mutual trust, positive emotions, and a stable business cycle, and ultimately fosters continuous positive relationships.¹⁸

From a service provider’s perspective, a high intention for continuous relationships can lead to sustained profits, while from that of a customer, maintaining an association with a company can offer various benefits. In essence, the intention for a continuous relationship can be seen as an exchange of values with service provision and repeated visits; it manifests as word-of-mouth effects, loyalty, and intent to recommend.

To illustrate this concept in the context of healthcare services, consider the following example. The fundamental principle behind increasing revenue in healthcare services is to elevate customer satisfaction, thereby boosting customer retention rates and fostering trust to attract other potential clients. The direct revenue surges with increasing revisits by the existing customers, and once they are satisfied with the service, their intention to recommend the service to other people increases. The outcomes include retaining the existing customers and attracting the new ones.

This increases the revenue and decreases the marketing costs. Thus, the intention for continuous relationships among the existing customers offers dual benefits of direct revenue growth and indirect cost savings, highlighting it as a major asset within the service industry.¹⁹

Hypotheses and Study Model

Based on previous studies, this study introduced procedural justice as a precursor to the two dimensions of trust perceived by patients in their relationship with physicians. Furthermore, we empirically investigated its effects on the intention for continuous relationships among patients—the consumers of healthcare services.

The Relationship Between Procedural Justice and Cognitive Trust

Procedural justice can be defined as the consumers’ perception of how objectively and fairly processes and rules are communicated to the final customer (consumer).^11,20 Consumers form trust based on several processes being conducted through fair procedures. Specifically, a provider with fair procedures or practices establishes a positive reputation that in turn leads to trust in the relationship between a supplier and buyer.^21,22

Cognitive trust built based on procedural justice can be seen as confidence in work processes. While adhering to work processes does not guarantee outcomes, the belief that the process is rational is a fundamental step for service providers and consumers to approach their desired outcomes. Therefore, cognitive trust originating from procedural justice can be considered a crucial link to reaching the ultimate goal.²³

Furthermore, procedural fairness extends beyond an organization’s work processes to one’s confidence in the expertise, integrity, and basic competence of individual service providers. For example, within the healthcare service institutions equipped with accumulated expertise and optimal systems, consumers can develop confidence in the individual service providers who adopt and have confidence in such systems as experts.^24,25

Additionally, the healthcare system has transitioned from a physician-centered system in the past to a patient-centered system today, where patients have the ability to choose physicians. Specifically, while patients in the past have simply followed their physicians’ orders, those today are directly involved in their treatment processes and developed objective views, where being dissatisfied with the treatment process and outcomes undermines their trust in the physicians.²⁶ Taken together, procedural justice is a critical factor in cognitive trust, which encompasses perceptions of the other party’s abilities and expertise, and can be established when these processes are carried out fairly. Thus, we established the following hypothesis:

Hypothesis 1: Procedural justice has a significant positive effect on cognitive trust.

The Relationship Between Procedural Justice and Affective Trust

Procedural justice refers to the degree to which individuals perceive the criteria or processes used to obtain outcomes as fair; it is a fundamental type of justice required for building trust relationships.²⁷ People who experience and observe procedural justice tend to perceive justice when outcomes are obtained through a fair process as opposed to focusing on short-term convenience, and perceiving procedural justice is likely to lead to long-term trust relationships.²⁸

However, trust is the tendency to rely on one another and signifies the belief that they will engage in positive actions or not act negatively toward each other. Trust is not formed through short-term actions; it requires verification over an extended period, encompassing not only the competence of the service provider, but also the processes and systems of the service-providing organization.

The trust formed through this process is called affective trust, implying one’s belief that the other party holds affection for them and will make positive decisions and actions for them. This confidence allows one to trust and delegate tasks that require risk-taking or patience. As complex medical practices often require long-term investment, customers may not attain immediate results. However, affective trust allows individuals to have faith and wait until they achieve significant outcomes.

Accordingly, procedural justice and trust are highly correlated, as documented in numerous studies.^29,30 Additionally, Korsgaard et al³¹ empirically analyzed that the relationship between procedural justice and trust has a significant positive impact. In summary, ensuring justice in the procedures of attaining an outcome can foster affective trust in the other party. Thus, we established the following hypothesis:

Hypothesis 2: Procedural justice has a significant positive effect on affective trust.

Relationship Between Cognitive Trust and Intention for a Continuous Relationship

Cognitive trust is a form of trust that is built based on the other party’s competence and expertise.³² Specifically, it refers to a rational and objective level of trust, grounded in capabilities and professionalism, rather than emotions. This type of trust plays a crucial role in business-to-business and business-to-consumer relationships. It is especially important in the healthcare service industry that deals with patients’ lives, and manifests in various forms of intention for continuous relationships.

In the healthcare industry, the intention for continuous relationships refers to the intent to maintain a relationship with the healthcare service providers after receiving their services; it encompasses the intention to revisit, the willingness to accept, and the intention to recommend. For instance, if customers perceive that the healthcare service provider’s system and the objective competence of its members align with their expectations, they develop an intention to revisit. Furthermore, this intention to revisit is coupled with their objective to gladly accept the instructions or guidance of the healthcare provider, ultimately enhancing their satisfaction.^33,34 Lastly, satisfied consumers can share their experiences with others (word-of-mouth) and recommend the facility to others. Individuals who utilize healthcare services based on recommendations enter into the service with an already established cognitive trust.

In summary, the formation of the intention for continuous relationships based on cognitive trust not only implies long-term orientation, but also yields intangible and tangible improvements within the service supply chain. Additionally, there is a cyclical effect in a place where the intention to recommend creates a foundational trust that leads new consumers to use the service while already having their cognitive trust established. Thus, we proposed the following hypothesis:

Hypothesis 3: Cognitive trust has a significant positive effect on the intention for continuous relationships.

Relationship Between Affective Trust and Intention to Continue the Relationship

Trust, a concept commonly associated with faith in another party,³⁵ has been interpreted and studied differently in various academic disciplines. In contrast to cognitive trust, which is based on the other party’s competence, affective trust refers to trusting and relying on the other party emotionally, encompassing aspects such as kindness and the degree of friendliness displayed toward the other party.³²

In essence, those who have trust do not choose short-term alternatives in order to maintain a long-term and continued relationship with their partner, as explored by several prior studies. One research reported that a high level of mutual faith results in repurchase intention even if satisfaction with the company is.³⁶ Thus, the trust perceived by customers is shaped through continuous interactions between the parties involved in a transaction,³⁷ and once it is established, the service industry customers tend to use the service continuously, ultimately reaping more benefits.³⁸

In the field of healthcare services, while medical expertise is essential, physicians’ warm attitude and attentive care for the patient not only help attain therapeutic effects, but also drive the patients to continue using the service.³⁹ Lastly, businesses can enhance long-term relationships and customer loyalty through employees’ friendly and kind attitudes toward customers.⁴⁰ Therefore, sincerely instilling trust in the other party without ulterior motives is likely to foster a continuous relationship. Thus, we established the following hypothesis:

Hypothesis 4: Affective trust has a significant positive effect on the intention for continuous relationships.

We established the hypotheses based on the aforementioned discussions; further, the study model consisted of four factors: procedural justice, cognitive trust, affective trust, and intention for continuous relationships. Figure 1 shows the study schematic.

Figure 1.

Study model.

Empirical Analysis

Data Collection and Study Method

The sample for an empirical analysis comprised people living in South Korea. To evaluate the validity of the study prior to distributing the questionnaire, we sought advice related to the questionnaire items from healthcare professionals throughout February 2023. Further, to enhance its readability, a preliminary survey was administered to three individuals who obtained a PhD in the last 3 years, based on which the final questionnaire items were chosen; each item was rated on a five-point Likert scale consisting of one “strongly disagree,” three “neutral,” and five “strongly agree.” The study questionnaire was administered throughout March 2023 through Kakaotalk, a messenger service most widely used in Korea. Overall, 1700 questionnaires were distributed, and 384 were collected and analyzed (collection rate 22.59%).

We used structural equation modeling to test the hypotheses. It not only allows simultaneous analyses of the structural relationships among the latent variables, but also enables deriving inferences for the relationships among the constructs. It is widely utilized in various social science fields in addition to business administration owing to these advantages.

Characteristics of the Study Sample

The most common age group was the 60s, followed by the 50s and 40s; the majority of the individuals lived in Busan Metropolitan City. The most common medical specialty visited the latest was internal medicine, followed by ENT, surgery, and neurology. Finally, the most common number of hospitals visited recently ranged from 1 to 5. Primary care hospitals were visited most commonly, followed by secondary and tertiary hospitals. Table 1 shows the general characteristics of the sample.

Table 1.

Demographic Characteristics of the Study Sample.

Latent variable	Measurement variables	Operational definition	Reference
Procedural justice	Explanation adequacy	Extent to which the doctor explains valid reasons when making treatment-related decisions	Colquitt et al,⁴¹ Jung et al⁴²
		Patient-centricity (Voice)	Extent to which the doctor takes the patient’s opinions into consideration when making treatment-related decision
		Procedure adherence	Extent to which the patient believes that the doctor carries out treatment procedures correctly
Cognitive trust	Accept expert opinions	Extent to which the patient accepts the doctor’s professional opinion	Kim et al,⁴³ Kimiagari and Asadi Malafe⁴⁴
		Trust in know how and expertise	Extent to which the patient is satisfied with the doctor’s expertise and professionalism
		Trust in job competency	Extent to which the patient trusts the doctor’s competence
		Trust in unrivaled knowledge	Extent to which the doctor believes that he or she has unique knowledge
Affective trust	Honesty	Extent to which the patient thinks the doctor is honest and diligent	Kim et al,⁴³ Kimiagari and Asadi Malafe⁴⁴
		Openness	Extent to which the patient believes that the doctor does not have a hidden intention
		Respect	Extent to which the patient thinks the doctor accepts the patient’s perspective and arguments
Intention for a continuous relationship	Preference	Extent to which one would prioritize the hospital visited for future medical needs	Anderson and Weitz,²¹ McDougall and Levesque⁴⁵
		Financial loyalty	Extent to which one would continue to use the hospital visited even if the medical expenses increase
		Continuity	Extent to which one would continue to use the hospital visited regularly
		Recommendation	Extent to which one would recommend the hospital visit to others

Definition and Measurement of Variables

To ensure the content validity of the latent variables, we used 14 measurement variables based on the previous literature. Table 2 shows the definitions and references for these variables.

Table 2.

Constructs and Measurement Items.

Latent variable	Operational definition	Reference
Procedural justice	Extent to which the doctor explains valid reasons when making treatment-related decisions	Colquitt et al,⁴¹ Jung et al⁴²
		Extent to which the doctor takes the patient’s opinions into consideration when making treatment-related decision
		Extent to which the patient believes that the doctor carries out treatment procedures correctly
Cognitive trust	Extent to which the patient accepts the doctor’s professional opinion	Kim et al,⁴³ Kimiagari and Asadi Malafe⁴⁴
		Extent to which the patient is satisfied with the doctor’s expertise and professionalism
		Extent to which the patient trusts the doctor’s competence
		Extent to which the doctor believes that he or she has unique knowledge
Affective trust	Extent to which the patient thinks the doctor is honest and diligent	Kim et al,⁴³ Kimiagari and Asadi Malafe⁴⁴
		Extent to which the patient believes that the doctor does not have a hidden intention
		Extent to which the patient thinks the doctor accepts the patient’s perspective and arguments
Intention for a continuous relationship	Extent to which one would prioritize the hospital visited for future medical needs	Anderson and Weitz,²¹ McDougall and Levesque⁴⁵
		Extent to which one would continue to use the hospital visited even if the medical expenses increase
		Extent to which one would continue to use the hospital visited regularly
		Extent to which one would recommend the hospital visit to others

Reliability and Validity Evaluation

Reliability represents the consistency of measurement of the desired construct. Various methods are used to test reliability, however, Cronbach’s alpha is most commonly employed in social sciences. A value of 0.7 or higher is considered to indicate good reliability.⁴⁶ The Cronbach’s alpha for our study variables was .848, .865, .751, and .875 for procedural justice, cognitive trust, affective trust, and intention for continuous relationships, respectively, indicating good reliability.

A confirmatory factor analysis was used to test the validity of the causal relationship among procedural justice, the two dimensions of trust, and the intention for continuous relationships. First, the measurement model had an acceptable fit, with the goodness of fit index (GFI), resting metabolic rate (RMR), root mean square error of approximation (RMSEA), Tucker–Lewis index (TLI), comparative fit index (CFI), Standardized Root Mean Square Residual (SRMR), and Chi-Square Divided by Degrees of Freedom (CMIN/DF) 0.948, 0.024, 0.052, 0.973, 0.979, 0.450, and 1.603, respectively.⁴⁶ To analyze the convergent validity of the study variables, we calculated the average variance extracted (AVE) and construct reliability (CR). In general, an AVE of 0.5 or higher and a CR of 0.7 or higher indicates good convergent validity.⁴⁶ Table 3 shows the results of the convergent validity analysis.

Table 3.

Convergent Validity.

	AVE	CR
Procedural justice	0.652	0.895
Cognitive trust	0.649	0.872
Affective trust	0.631	0.882
Intention for a continuous relationship	0.694	0.960

Further, discriminant validity represents the differences among independent latent variables. To meet the criterion, the AVE must be greater than the square of the correlation coefficient between the two constructs. In our study model, the largest correlation coefficient and minimum AVE was .556 and .631, respectively, confirming that the discriminant validity is established. Table 4 shows the results of the discriminant validity analysis.

Table 4.

Discriminant Validity (Square of Correlation Coefficient Excluding Diagonals).

	Procedural justice (1)	Cognitive trust (2)	Affective trust (3)	Intention for a continuous relationship (4)
(1)	.652
(2)	.556	.649
(3)	.531	.512	.631
(4)	.389	.456	.389	.694

Hypothesis Testing

This study tested the hypothesis that procedural justice affects the intention for continuous relationships through trust. First, the fit of the structural model using the maximum likelihood method was GFI = 0.978, RMR = 0.025, RMSEA = 0.052, TLI = 0.972, CFI = 0.978, meeting the recommendations by Hair et al.⁴⁶ Thus, we examined the hypothesis (Table 5). Procedural justice had a significant effect on the two dimensions of trust; they had a positive effect on the outcome measure (intention for continuous relationships).

Table 5.

Hypothesis Testing.

Path	Standardized coefficient	Unstandardized coefficient	S.E.	C.R.	P	Result
Hypothesis 1	0.910	0.757	0.052	14.572***	.000	Adopted
Hypothesis 2	0.931	1.041	0.070	14.910***	.000	Adopted
Hypothesis 3	0.509	0.541	0.115	4.719***	.000	Adopted
Hypothesis 4	0.297	0.235	0.085	2.767**	.006	Adopted

P < .05. **P < .01. ***P < .001.

Conclusion

Summary of the Study Findings

In contemporary society, factors such as population aging and increased education levels have led to a mounting interest in the service industry, most noticeably in healthcare services. However, research with a comprehensive approach encompassing the entire spectrum of healthcare service delivery, customer perception, and satisfaction remains scarce. The concept of fairness has predominantly been utilized within the context of organizational behavior (OB); however, research addressing fairness within the healthcare service domain is relatively scarce.^47,48 Hence, this study empirically analyzed the two dimensions of trust and procedural justice that can help maintain the relationship between healthcare service providers, specifically physicians, and service recipients (patients). Its findings have been outlined as follows.

First, procedural justice had a positive impact on cognitive trust. This aligns with previous research findings indicating that customers can form trust based on whether service providers deliver processes and rules objectively and fairly.^11,20 Furthermore, as healthcare services have transitioned to more patient-centered approaches today, patients who feel dissatisfied with the treatment process and outcomes tend to adopt an objective view of physicians and develop mistrust in the physician.²⁶ Therefore, recognizing the importance of procedural justice is essential for the establishment of cognitive trust, which is formed based on the other party’s expertise and competence, within the service sector, namely healthcare services.

Second, procedural justice had a positive impact on affective trust. It is a fundamental element in forming trust relationships.²⁷ Specifically, Reis²⁸ argued that people are more likely to build long-term trust relationships through outcomes obtained through fair procedures rather than short-term conveniences. Translating this into the context of healthcare services, providing these amenities also requires a long-term investment. Specifically, even if it takes time, physicians who treat patients with sincerity and fair procedures are able to foster mutual trust. Therefore, in any endeavor, perceiving certain criteria or processes of obtaining an outcome as fair cultivates affective trust that is based on emotions.

Third, cognitive trust and the intention for a continuous relationship also showed a significant positive impact, consistent with previous research findings. In the healthcare industry, which directly or indirectly deals with human lives, the competence of physicians are of paramount importance. Therefore, from the patient’s perspective, patients are more likely to revisit the hospital if its physician displays abilities that align with their expectations. When patients revisit the hospital, they not only build trust in the physician, but also develop a willingness to accept the latter’s instructions.^33,34 As patients are satisfied with the services received and thus revisit the hospital, they will share their healthcare service experiences with people around them through word-of-mouth and recommend the services. Thus, physicians’ expertise and competence are essential in order to maintain a continuous relationship between them and patients.

Finally, affective trust had a significant effect on the intention for a continuous relationship. In contrast to cognitive trust, which is based on competence, affective trust signifies the degree of kindness and friendliness displayed toward the other party.³² This type of trust is more important in long-term relationships than the short-term ones and is characterized by a stronger subjective perspective rather than objectivity. Similarly, Rust and Williams³⁶ argued that customers develop an intention to repurchase if there is trust, even if they have low satisfaction with the company. Additionally, Garbarino and Johnson³⁷ emphasized that trust must be the basis of a relationship between the transaction parties in order to form ongoing relationships. In the healthcare industry, this means that physicians treating patients warmly and exhibiting humane attitudes with professional medical care motivates patients to trust the physician as a person and continue to seek their care. Thus, it is essential for physicians to provide medical services to patients with honesty without hidden intentions.

Implications of the Study

The findings have several implications. First, the result that the two dimensions of trust—cognitive and affective—affect the intention for continuous relationships underscores the importance of trust among the healthcare professionals, including physicians. Patients, who are clients within healthcare services, tend to experience high anxiety levels during their service encounters, primarily because their health is at stake. Thus, physicians must strive to instill trust in their patients. Our results indicated that with trust, patients feel less uncertainty and ultimately develop stronger intentions to continue their association with the physician. Thus, this study is significant in that it highlighted the significance of trust, in addition to patient satisfaction, for healthcare facilities to thrive in a competitive business environment.

Second, this study holds academic and practical applicability that extends beyond healthcare services to the general service or marketing domains. In recent years, client experience has emerged as an important keyword in the service and marketing sectors. Procedural justice, combined with outcome satisfaction, is a vital factor in providing an overall sense of satisfaction with the service received. This study highlighted that the psychological satisfaction stemming from the service delivery process and interactions within the healthcare system carries equal significance with the service outcome (disease treatment) within the healthcare sector. Importantly, this insight can be extended and applied to a broad spectrum of service industries, providing valuable and universally applicable implications.

Third, this study divided trust into cognitive and affective trust and examined the paths through which they lead to satisfaction. The findings confirmed that both qualitative and quantitative components affect the relationship orientation. This further emphasized the importance of qualitative satisfaction in healthcare services, similar to the principle of procedural justice that encompasses the process and outcome. Although affective trust was not quantified, we showed that the qualitative aspect has a similar impact on the service outcomes as quantitative factors. Therefore, healthcare service providers should consider the experiential aspects perceived by users.

Finally, this study introduced new measurement items tailored to the perspective of healthcare service customers that was not done previously. Specifically, while procedural justice, cognitive trust, affective trust, and intention for a continuous relationship were based on previous research, we viewed them in the context of a specific industry and proposed a different approach, adding depth to the existing research.

Limitations of Study and Recommendations for Future Research

Despite these implications, this study has a few limitations, and we present several recommendations for the future research. First, we only examined procedural justice, which is only a component of organizational justice. However, organizational justice also includes interaction and distribution justice. Thus, future studies should examine the roles of each of these factors to highlight the importance of justice in the healthcare service sector. Second, the service industry-related studies use satisfaction and intention to continue using services in addition to the intention for a continuous relationship as their outcome measures. This study only used one outcome measure; thus, future studies should conduct a more expanded investigation by adding more measures. Finally, we administered the questionnaire to patients visiting hospitals, however, could not survey when they experienced the healthcare services. If some participants responded to the survey based on hospital visits that occurred a long time ago, their responses may be less reliable. Thus, subsequent studies should visit hospitals personally to administer the study questionnaire to the patients.

Footnotes

Contribution List

Conceptualization: Changjoon Lee, Methodology: Changjoon Lee, Validation: Soohyo Kim, Formal analysis: Changjoon Lee, Writing (original draft): Changjoon Lee, Writing (review and editing): Young-Kyou Ha, Data curation: Soohyo Kim, Supervision: Young-Kyou Ha.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Informed Consent

Prior to distributing the questionnaire used in this study, patients’ responses were notified in advance that they would be used of the study. And the authors telling you that we did a survey of people who agreed it, and did not used data of people who did not.

Ethical Permission

This study surveyed patients who had experienced medical services. And in this study, regardless of their diseases, as ethics commitment is considered unnecessary as a survey was conducted on their relationship with medical staff.

ORCID iD

Changjoon Lee

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