The first part of the Discussion will discuss the findings from the observations at Slagelse and Roskilde Sygehus, including the findings from the employee presentation. The discussion will be categorized in themes similar to the basic and organizing themes from the findings. All findings will be discussed in relation to the literature review by identifying coherences and conflicts. Lastly, there will be discussed contributions to business and literature. The discussion will be followed by the last part of the thesis: the conclusion.
Based on the Organizing Themes
The observation studies from Slagelse Sygehus and Roskilde Sygehus both have some resemblance and disparities. The different organizing themes will be discussed between the two hospitals but also in correlation with the literature review presented earlier in this thesis. The discussion of the organizing themes will begin by discussing how the physical surroundings influence the patient experience, followed by how emotions and employees can have an influence on the patient experience. Lastly, there will be a discussion on the overall patients experience of the waiting areas at the pediatric outpatient clinic at Roskilde Sygehus where the global themes of both Slagelse and Roskilde Sygehus will be discussed.
How the Physical Surroundings Influenced the Experience
Bitner (1992) argues that the impacts of the physical surroundings and how it influences the behavior is particularly apparent in hospitals. Thus, this part of the discussion will go more in-depth with the physical surroundings observed at Slagelse and Roskilde Sygehus, and the observed behavioral impacts.
Organizing theme 2 of Slagelse and Roskilde Sygehus is about the interior and atmosphere, and how it influences the experience of the patients. Dhebar (2012) argues that a customer must feel welcomed when visiting a place, which in this situation will be the patient visiting the hospital. It was observed that the young patients showed frustration about not being able to play with the toys cluttered away in the middle of the waiting hall of Roskilde Sygehus (basic theme S), which could
Because of the covid-19 restrictions being a state of emergency, it is difficult to find the direct coherences in the literature. Lemon & Verhoef (2016) does however, argue that the external environment, such as extreme crisis can have a significant influence on the experience. In overall all aspects, including the physical surroundings has influence on the experience, covid-19 restrictions or not (Bitner, 1992; Meyer & Schwager, 2007).
As the global themes indicate the physical surroundings at Slagelse Sygehus are argued to be better suitable for the needs of the patients than the ones of Roskilde Sygehus: there were observed more approach behavior at Slagelse, than Roskilde (Bitner, 1992). At Roskilde Sygehus the toys cluttered ways in the middle of the waiting hall do not only feel unwelcoming, but can cause a high level of avoidance behavior, as the young patients cannot interfere with the touchpoints (Bitner, 1992). At Slagelse Sygehus the observed covid-19 restrictions with tape closing of areas of waiting room 1 can cause avoidance behavior as well, however the rest of the physical surroundings waiting room 1 seemed to cause approach behavior (Bitner, 1992).
The messiness of how the covid-19 restrictions were carried out at Roskilde Sygehus arguable led to less satisfaction between the patients and relatives, however if it had been carried out in a more organized and tidy way it could have led to higher satisfaction (Hutton & Richardson, 1995).
The experience when arriving at Roskilde Sygehus and have difficulties finding directions for the pediatric outpatient clinic (and other wards) can cause avoidance behavior, as the patients and relatives do not feel proper welcomed (Bitner, 1992; Dhebar, 2012). In addition, Bitner (1992) argues that signs are important when patients and relatives form their first impressions of the hospital, making it crucial for Roskilde Sygehus to improve their signing all over the hospital. Luckily the employees sitting at the reception in the waiting hall of the pediatric ward are good in trying to remedy this for the patients and relatives.
At Slagelse Sygehus it was found that animals and recognizable figures on the walls were good for conversations, and that the patients found them interesting (basic theme D). Likewise, it was found that the patients at Roskilde Sygehus also had interest in the of sea animal pictures on the walls (basic theme P). This seems to be a finding that goes beyond the litterature studied for this research, however it does not seem like a new phenomenon. It can be argued that as patients feel safe around
familiar surroundings and as many children have a knowledge of animal pictures and Mickey Mouse made the physical surroundings familiar (Hutton & Richardson, 1995).
The brand-owned touchpoints like the hopscotch and small scooters for the young patients at Roskilde Sygehus was found to cause approach behavior from both patients, relatives, and employees (Bitner, 1992; Lemon & Verhoef, 2016). As these touchpoints mostly have a positive influence on the patient experience, they will likely become a part of the patient’s expectations for next time coming to the pediatric outpatient clinic (Hutton & Richardson, 1995; Meyer & Schwager, 2007). It is possible that these touchpoints have had high value for some of the youth patients when they were young patients, but as their interest might change over the years, so does the value of the hopscotch and small scooters (Dhebar, 2012; Meyer & Schwager, 2007).
The different levels in waiting room 1 at Slagelse Sygehus (basic theme F) made the physical surroundings more dynamic and it was found that it can cause an approach behavior from both patients and relatives (Bitner, 1992). However, it was at the same found that this type of interior is not expected as typical interior for a hospital making it a clash with the theory of Hutton &
Richardson (1995) arguing that a typical healthscape will lead to higher patient satisfaction. At the same time the rest of the interior at the pediatric outpatient clinic of Slagelse Sygehus was found to be typical for hospitals. Therefore, it could be a possibility that waiting areas are an exception of the argument of how health care facilities need to have typical interior. This may be because the waiting areas are a place to deal with possible negative emotions before a consultation. A discussion of the experienced emotions in the waiting areas will presented later.
The noises from crying patients, relatives, employees, and interior were found to be disturbing and interfering with the atmosphere of the waiting areas at both Slagelse Sygehus (basic theme E) and Roskilde Sygehus (basic theme T). In another setting where there would naturally be more talking, like e.g., a canteen, the sounds from a radiator would probably not be that disturbing. But at hospitals the unspoken rule of the physical environment is that patients and relatives are quiet in the waiting areas (Bitner, 1992), as it was also found that a patient was being silenced by their relative. The clock on the wall in waiting room 2 at Slagelse Sygehus was found to be some sort of a break from the unspoken rule because it made a loud sound, which was enjoyed by a patient and relative.
The third organizing theme of Slagelse Sygehus is concerned about how youth patients have other needs than the young patients, for which reason Slagelse has developed a waiting room only to facilitate these needs (basic theme G). As Dhebar (2012) argues, it is important that the customer feels genuinely invited, which Slagelse Sygehus has made an effort in doing so for both their youth and young patients by designing appealing waiting areas with different needs for different interest and ages. However, waiting room 3 at Slagelse Sygehus was not taking in to use at the time of the observations, so it was not possible to observe how the youth patients would react on it. The insights on waiting room 3 from Slagelse Sygehus is still relevant, as it could stand of an example on why and how Roskilde Sygehus could do something similar for their youth patients.
Hutton & Richardson (1995) argues that it is important that the health care facilities (touchpoints) are designed to facilitate the target patient group, which at the pediatric outpatient clinic at Roskilde Sygehus are both young and youth patients. The observations from Roskilde Sygehus did however show that there was a lack of touchpoints facilitating the needs of their youth patients (basic theme Y), as they arguably did not find value in the same touchpoints as the young patients (Meyer &
Schwager, 2007; Lemon & Verhoef, 2016). It is therefore arguable that the youth patients at Roskilde Sygehus do not feel welcomed, and it is crucial that this is changed to improve the patient journey of the youth patients (Dhebar, 2012).
How the Emotions Influenced the Experience
The first organizing theme of Slagelse Sygehus “Having fun makes the waiting time go faster” is based on how employees’ initiatives on how to keep good hygiene, drawing, and playing can ease the waiting time and make it more fun. These observations are based on brand-owned touchpoints, as Slagelse can control the initiatives, possibilities for drawing and playing with toys (basic theme B) (Lemon & Verhoef, 2016). Though the last two was limited due to covid-19, it can still help in reducing the feelings about being anxious and afraid like the rest of the interior (Corsano, Majorano, Vignola, Guidotti, & Izzi, 2015).
At Roskilde Sygehus it was observed how the young patients wanted to play while being in the consultation rooms but the options of this was scarce due to covid-19 restrictions (basic theme Y).
This is found to be a substantial support of why there should be drawing possibilities and toys in a waiting room; namely to reduce the negative feelings the patients might experience and make the
time in the waiting areas and consultation room more positive (Corsano, Majorano, Vignola, Guidotti, & Izzi, 2015).
The findings from Slagelse Sygehus also showed a mother and her son taking a picture of the hygiene song (basic theme A), making it possible for the song to become a touchpoint in the post-core service encounter, as it will take the minds back to the core service encounter in the waiting room at the hospital (Vorhees, et al., 2017).
Organizing theme 4 at Slagelse Sygehus illustrates how different feelings, emotions, and behaviors were observed in the waiting areas. The third organizing theme at Roskilde Sygehus illustrates the same, however, the basic themes of the two hospitals varies.
One of the observed basic themes at both hospitals, were on the use of phones and tablets while waiting (basic theme I, Slagelse Sygehus, basic theme W, Roskilde Sygehus). The phones and tablets are customer-owned touchpoints, as the hospitals cannot control how and when the patients use them (Lemon & Verhoef, 2016). However, Roskilde Sygehus could have an app, which could function as both an information source about the waiting and consultation time, and at the same time have different games for both young and youth patients. The app would be brand-owned, but with partner influence, as noted earlier (Lemon & Verhoef, 2016). The app could include games about medical instruments and procedures making them less frightening and more relatable for the patients in the consultation (Corsano, Majorano, Vignola, Guidotti, & Izzi, 2015).
At the same time, the app could have an interspace where the youth and young patients could find information about how everything works in a hospital, and/or maybe find answers to questions that they did not know they had, or maybe did not want to ask their relatives about. The app and electronic devices in general offer a virtual world, where the patient can instantly zoom out of the physical and emotional surroundings of the waiting room, offering them a virtual and instantly distraction.
Rosebaum, Otalora, & Ramírez (2017) presents how a mall was designed with areas for shoppers to post photos of themselves from the shopping experience on social media, and thereby increase the word-of-mouth communication in the post core service encounter. In a similar way the app could have a function where it could be possible to share the results of the games on the patients’ social
media accounts (Rosenbaum, Otalora, & Ramírez, 2017). The cinema company Nordisk Film have an app BioSpil5 which has some features that could also be relevant for the waiting time at Roskilde Sygehus (or any hospital for that matter).
This could be an app, that could have touchpoints at all three stages of the patient journey. The app could of course also provide Roskilde Sygehus with useful data, but this will not be taken into further depth. However, there is also an ethical question to be asked at this point, such as how healthy screen time are in general, and if a hospital should provide more screen time or rather try to reduce it by offering other touchpoints that create possibilities for the patients to be physical, creative, or mentally involved.
In overall it could be argued that the phones and tablets where in fact a positive input to the patient experience in a state of emergency with covid-19 restriction, when e.g., toys were not to be used.
Thereby it could also be argued that if the phones and tablets are being used anyways, it could just as well be with a touchpoint that Roskilde Sygehus could partly control.
Slagelse Sygehus has a basic theme concerned about how many patients and relatives showed emotions of joy (basic theme J). This could be aligned with the fact that they do in fact feel welcomed, and that the touchpoints are designed to address their needs (Dhebar, 2012). Emotions of joy were also observed at Roskilde Sygehus (basic theme X), but not in the same amount as it was at Slagelse Sygehus. It can be discussed that this is because of the variations of their physical surroundings, handling of covid-19 restrictions, and touchpoints.
The patients at both Slagelse (basic theme K) and Roskilde Sygehus (basic theme X) was observed to be showing emotions of sadness, anxiousness, and fear, alongside with emotions of boredom (basic theme L, Slagelse Sygehus, basic theme Z, Roskilde Sygehus). This is aligned with earlier studies that shows that the negative emotions are the reasons why it is important to investigate in the patients’ emotional stages in the waiting rooms (Corsano, Majorano, Vignola, Guidotti, & Izzi, 2015). As it is stated by Corsano, Majoraono, Vignola, Guidotti, & Izzi (2015), it is necessary for
5 Biospil is an app by Nordisk film with games developed for the waiting time before the movie begins in the cinema. One of the games is an interactive game between all the users sitting in the cinema, and the results will
waiting rooms in pediatric outpatient clinics to be equipped with toys and pleasant physical spaces in order to help the patients relax and cope better with their medical care. The importance of this is taken into consideration at both Slagelse and Roskilde Sygehus, as all their waiting areas contains toys and an attempt to create a pleasant physical space. It can be discussed if this attempt is succeeded or not in the waiting room at Roskilde Sygehus, as the findings here show that the interactions with the interior was low from the patients, and the physical surroundings were boring and unpleasant with multiply disturbing noises (basic theme T) (Bitner, 1992).
At both Slagelse and Roskilde Sygehus it was observed that some patients were crying, while waiting and coming in and out of the consultation rooms. The sounds of this can cause negative emotions to other patient and relatives waiting (Bitner, 1992). It is relevant to discuss how a patient’s negative feelings and emotions influence not just the experience but also the perception of the employees (Bitner, 1992).
The findings from Roskilde Sygehus illustrate that some patients showed fear for the medical instruments (basic theme X), but in most observed situations it was found that the young patients showed an interest in the medical instruments (basic theme Q). However, the chosen literature for this thesis states how pediatric patients showed their negative emotions through drawing medical instruments which can be discussed as a way of showing fear connected to said instruments (Corsano, Majorano, Vignola, Guidotti, & Izzi, 2015).
Prior research shows that younger patients feel more fear about being at the hospital than youth patients, probably because of the knowledge of pain has not fully developed (Corsano, Majorano, Vignola, Guidotti, & Izzi, 2015). The observations also showed that only young patients were crying at both Slagelse and Roskilde Sygehus, whereas youth patients seemed indifferent to the fact of pain, and more bored by the situation than afraid. It is argued that youth patients show more anxiety than the young patients (Corsano, Majorano, Vignola, Guidotti, & Izzi, 2015), although this was not observed at either Slagelse or Roskilde Sygehus.
It was also found that most of the patients and relatives at Slagelse and Roskilde Sygehus accepted the waiting time, which is well aligned with previous research (Corsano, Majorano, Vignola, Guidotti,
& Izzi, 2015). However, it is also argued that (adult) relatives find help in the presence of other adults
and the possibility to share their emotions with them (Corsano, Majorano, Vignola, Guidotti, & Izzi, 2015): they like positive and social spatial distraction. This was not found to be the situation at either Slagelse or Roskilde Sygehus, but it can be argued that the lack of conversation with others also had something to do with the covid-19 restrictions. It can also be argued that the lack of conversations is due to the cultural differences, as the research by Corsano, Majorano, Vignola, Guidotti, & Izzi (2015) are from an Italian hospital.
It is though noticeable that in situations where the fear of the unknown was high, like mentioned at Roskilde Sygehus (basic theme X), two relatives (presumably mother and father) show up to go to the consultation with the patient where the fear of negative outcome is present, which can be discussed to be aligned with the previous findings showing that sharing emotions helps to relax during waiting times Corsano, Majorano, Vignola, Guidotti, & Izzi, 2015) as the relatives can share their emotions with each other.
How the Employees Influenced the Experience
At Roskilde Sygehus the first organizing theme is regarding the employees, and how they influence the patient experience. Overall, the observations showed that the employees were in a good mood towards each other, the patients, and the relatives (basic theme O). Bitner (1992) argues that a good physical surrounding for patients should also be good for employees and vice versa. Thus, the physical surroundings should simultaneously support the needs of both the patients and the employees (Bitner, 1992). The quote on how an employee jumped on the hopscotch at Roskilde Sygehus (basic theme O) show how the same touchpoint in the physical surroundings can cause approach behavior from both patients and employees (Bitner, 1992). However, it was also found that there was one employee at Roskilde Sygehus that showed avoidance behavior, as the employee did not seem willing for another observation to take place in the same consultation room (basic theme O) (Bitner, 1992).
The hospital clowns observed at Roskilde Sygehus were a positive input to the experience and represents a partner-owned touchpoint (basic theme P) (Lemon & Verhoef, 2016). It can be discussed that the patients are not aware of that the hospital clowns are not employees of the hospital as of why it is argued that the hospital clowns fit the literature on employee interactions as well.
It is crucial for Roskilde Sygehus to provide strong relationships between their patients and employees, as Gualandi, Masella, Viglione, & Tartaglini (2019) argues these relationships are important and in particular in vulnerable situations. It was observed how some of the employees at Roskilde Sygehus was trying to create strong personalized relationships by showing interests in the patients’ personal life and playing with the patients in during the consultations (basic theme Q). The findings from both Slagelse Sygehus (basic theme L) and Roskilde Sygehus (basic theme Z) shows that the employees was apologizing for delays, which is argued to improve the relationship between the patients, relatives, and employees (Gualandi, Masella, Viglione, & Tartaglini, 2019).
The Patient Experience at Roskilde Sygehus
The findings show how Roskilde Sygehus has some great touchpoint that works for many of their young patients, such as the small scooters and the hopscotch (basic theme U), however the overall patient experience seems to be incomprehensible and lacking in offerings for the youth patients.
This is aligned with the literature stating that most companies are good at performing at the individual touchpoints, but the overall performance on the journeys can set a company apart (Maechler, Neher, & Park, 2016).
The overall patient journey must be taken into consideration when managing the patients experience, as it affects the final outcome. It will benefit Roskilde Sygehus to give the patient a distinctive journey experience, as it makes it more likely that the patient will be willingly to come back another time (Hutton & Richardson, 1995; Maechler, Neher, & Park, 2016). However, it can be argued that the patient may not have a choice if they are sick.
The global themes of both Slagelse Sygehus and Roskilde Sygehus are different as their waiting areas are managed differently. First of all, the handling of the covid-19 restriction was carried out in a better way at Slagelse Sygehus than Roskilde Sygehus. Secondly, Slagelse has a better coherence in their waiting areas than Roskilde. However, touchpoints such as the hopscotch and small scooters were found to be used by many at Roskilde Sygehus, and Slagelse Sygehus did not have similar touchpoints. Lastly, Slagelse Sygehus was observed to provide better touchpoints for both young and youth patients, but also in terms of patients having different interests.
It is crucial that the patient experience in the waiting areas of the pediatric outpatient clinic at Roskilde Sygehus is managed to fit the different needs of its patients best possible, as the physical surroundings can have measurable impacts on the patient’s healing process (Hutton & Richardson, 1995).
The discussion on the findings from the observations has provided a thorough understanding of the positive and negative elements and opportunities of waiting rooms, and that there is an incentive for improvement in several touchpoints in the physical surroundings. The next part of this thesis will present how this research area, question and design, and findings from both ethnographic observations and the employee presentation all contributes to business and literature.
Contributions to the Business
The contribution to business will take a stand in the discussion and in the employee feedback on the suggestions on how to improve the touchpoints from the employee presentation (appendix 7).
The contributions will be presented with eight propositions which can be applied in the business of pediatric health care: waiting rooms in hospitals, doctor practices, and specialized doctors.
However, the propositions may be applicable for other businesses where the conditions could be similar. Examples on this will be presented after the propositions.
Propositions for the Pediatric Health Care Business
The aim of the order of the propositions is to present them in the same order as they could be relevant in a patient journey.
Thus, the first proposition is concerned with the lack of signing from the main entrance of Roskilde Sygehus to the pediatric outpatient clinic (and other wards) which can be confusing and cause avoidance behavior (Bitner, 1992). As the physical surroundings influences both patients, relatives, and employees (Bitner, 1992), the findings from the employee presentation also show how the employees were commenting on this (employee D). A suitable proposition could be:
P1: Signing should be clear from the main entrance towards a pediatric waiting area
The next proposition was suggested at the employee presentation but with no feedback, however it was also presented for the ward managers as mentioned in the findings who took it into consideration almost immediately. As Bitner (1992) states the “perception of greater personal control in the servicescape increase pleasure” (p 63), which at hospitals can be gained by getting as much information on the medical treatment as possible. When delays occur and the patients and relatives do not know how much time they are going to wait there is a loss of control on the situation (Bitner, 1992). A possible suggestion could be to give following information when patients and relatives addresses the reception: the name of the employee who should be doing the medical treatment and which consultation room they will be going to when it is their turn, and lastly if there are any delays. Based on this, the following proposition is presented:
P2: As much as possible information about the consultation should be given at arrival
The third proposition is based on the suggestion based on getting some sound into the waiting room of Roskilde Sygehus, partly to cancel out the noises from the existing interior (basic theme T), but also because the servicescape is perceived holistically including alle senses (Bitner, 1992). An employee found the suggestions interesting but was reserved about how it should be carried out in practice (employee C). It was discussed that the sounding (touchpoint) should be connected to the interior (touchpoint). It can be argued that this is in line with theory of how the experience is perceived holistically (Bitner, 1992), and that all touchpoints are interfering with each other (Dhebar, 2012). Therefore, the following proposition are:
P3: The sounding in a waiting room should be connected to the interior
An example of this could be, that if a waiting room was decorated with sea animal pictures, painted in blue colors, had an aquarium, and a mermaid figure, there should be ocean sounds played in the waiting room.
As the findings shows one of the employees pointed out that the use of phones and tablets was suitable during covid-19 restrictions (employee E). However, it can be argued that the brand-owned touchpoints should be changed as the context of which they exist in changes (Dhebar, 2012; Lemon
& Verhoef, 2016). It was found that touchpoints that assumably were valuable for young patients, e.g., toys, before the covid-19 restrictions, had lost their value because it was not possible to use
them (basic theme S), which is aligned with the literature stating the value of touchpoints can change over time (Meyer & Schwager, 2007; Dhebar, 2012). The following proposition is thus suggested:
P4: When existing touchpoints cannot be used due to covid-19 restrictions (or other reasons) they should be managed to fit the context and new touchpoints should be explored to best facilitate the patient journey
An example of this could be to decorate the face shields like mentioned in employee presentation (appendix 7), or like the app suggestions discussed under the part How the Emotions Influenced the Experience.
As mentioned just above the value of touchpoints can change over time (Meyer & Schwager, 2007;
Dhebar, 2012) which makes it difficult to provide value for both young and youth patients at Roskilde Sygehus when their touchpoints mainly apply to young patients (basic theme V). An employee commented on this, as they found there was no offers for the youth patients (employee F). In addition, it is suggested that health care facilities should be designed to the patients using them (Hutton & Richardson, 1995). It is discussed that Slagelse Sygehus has succeeded in providing different waiting areas for all age groups (basic theme G), where the patients feel welcomed (Dhebar, 2012). Based on this the following proportions is presented:
P5: A waiting area should provide appealing touchpoints for pediatric patients in all age groups
The following proposition takes a standing point in the managing of brand-owned touchpoints and how they can have multiple functions and different effects depending on where in the patient journey they occur (Lemon & Verhoef, 2016). Some of the most valuable touchpoints for the young patients at Roskilde Sygehus were observed to be the hopscotch and small scooters (basic theme U) (Meyer & Schwager, 2007). At the employee presentation it was suggested to refine the touchpoint of the small scooters and provide a racetrack in the hallway and small parking spaces in front of the consultation rooms, however an employee found it to be too disturbing if the patients were to race through the hallway (employee G). Instead of a racetrack the employee suggested a running track in the hallway as it could both be used while waiting but also during consultations to
check the physics of a patient (employee G). The same employee did though find the idea of the parking spots suitable as they already let the patients park the small scooters by the consultation room during the consultation (employee G). Taking the touchpoints from the waiting areas in use during the consultation can also help with the patients who would like to play while being at the consultation (basic theme Y). The proposition therefore goes as:
P6: Touchpoints can be managed to have different functions in the journey
This proposition could be relevant in terms of former suggestion from the discussion of an app that could be a touchpoint in both the pre-, core, and post-core stages of the journey, as it could contain needed information before going to the hospital, have games for the waiting time, and provide needed information after the consultation as well.
The observation from Roskilde Sygehus showed that the young patients had an interest in the medical instruments (basic theme Q) and as it was discussed earlier medical instruments can seem frightening on young patients (Corsano, Majorano, Vignola, Guidotti, & Izzi, 2015). Which was also observed at Roskilde Sygehus (basic theme X). By having medical instrument toys in the waiting areas and consultation room the patients can gain more knowledge about the procedures and thereby more control of the situation which will have a positive impact on the experience (Bitner, 1992). The following proposition is suggested:
P7: Toys should take form of medical instruments
The last proposition is based on how the physical surroundings both influence the patients, relatives, and employees (Bitner, 1992) which is one of reasons it makes sense to include patients and employees in the developing of the brand-owned touchpoints in the servicescapes (Lemon &
Verhoef, 2016). This also reflects on the argument of Vandermerwe (1993) saying that if a hospital has appealing touchpoints, it is important that the employees have the competences to maintain the touchpoints. It is thereby argued that the more influence the employees have on the touchpoints, the more it will be fitted with their competences. Similar goes for the patients: the more they have a say in the touchpoints, the more it can be expected that they will interact with them. It is arguable that the relatives also could take part of this, however it is found that the needs of the patients should be prioritized over the needs of the relatives. Moreover, it is argued that the