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An ethnographic study of the waiting areas as part of the patient journey through the pediatric outpatient clinic of Roskilde Sygehus

Master thesis

MSc in Social Science – Service Management Copenhagen Business School

Author: Sif Thorhauge Winkel Larsen Student number: 124532

Submission date: November 15, 2021

Supervisor: Helle Haurum, Department of Marketing Characters (with spaces): 177.339

____________________

The Patient Experience

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Acknowledgments

I would like to acknowledge and thank the people who have contributed in one way or another to the preparation of my master thesis.

First, I would like to thank my supervisor Helle Haurum, who has been beyond what I had ever expected a supervisor could or should be. Helle helped me to believe in myself and my abilities which has been one of the main reasons why my process has been a good experience. Thank you, Helle, for showing me support and taking your role as a supervisor truly serious.

I would like to highlight my gratefulness to my dear friends as well: Thank you, Mikala, for taking the time to help me with collecting data. Thank you, Malia and Tim, for being my external partners providing me with feedback and supporting me both professionally and emotionally through this journey.

A big thanks to my parents, and sister Ronja, for being genuinely interested in my topic, believing in me, and always being there in any way possible.

I would especially like to express my gratitude to my husband, Andy, and our amazing daughter, Havana for always putting a smile on my face and showering me with love every day.

Lastly, I would like to thank the pediatric outpatient clinic of Slagelse Sygehus and its patients and relatives for the opportunity to collect data. The same goes for Roskilde Sygehus, its patients and relatives, employees, and Anita Pedersen and Malene Boas, who I would also like to thank for giving me the opportunity to validate my data with the employees. Thank you for providing me with the needed data.

Thank you all, I do not lie when I say, I could not have done this without every one of you.

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Abstract

This thesis is concerned with the patient experience of the touchpoints in the waiting areas as a part of the patient journey through the pediatric outpatient clinic of Roskilde Sygehus. The case of Roskilde Sygehus was chosen because the management of the outpatient clinic found a need to change their waiting areas immediately. The research of the thesis is based on the chosen literature within the areas of customer experiences, journeys, and touchpoints, and servicescapes, healthscapes, the patient experience and journey in aiming to connect the literature together as an in-depth review on the two areas of customer and patient experience combined.

The thesis is written within the field of Social Research with a hermeneutic approach meaning that the researcher’s personal values and perspectives influences the study. The empirical data was collected through a micro-ethnographic study of the pediatric outpatient clinic waiting areas of Slagelse Sygehus and Roskilde Sygehus, and an employee presentation of the temporary findings and suggestions for improvements at Roskilde Sygehus. The field notes from the observations were analyzed with thematic networks, where there together was found 24 basic themes and 7 organizing themes at Slagelse Sygehus and Roskilde Sygehus with a global theme for each thematic network.

The global themes were found to be: Slagelse Sygehus: The waiting areas provide the patients with physical surroundings which encourage approach behavior, and Roskilde Sygehus: The touchpoints in the waiting areas could be improved for all patients, youth patients in particular.

The findings were discussed in the fifth part of the thesis, where the observations from Slagelse Sygehus were used in comparison with those from Roskilde Sygehus, and together it was discussed in relation to the literature review by identifying coherences and conflicts. The discussion also includes contributions to literature and business. The latter suggesting a set of eight tangible propositions to be applied in the health care business.

The conclusion suggests that the management of the pediatric outpatient clinic at Roskilde Sygehus takes the eight propositions into consideration when improving their waiting areas. In addition, the conclusion also brings an attempt in answering why the research question is relevant to ask at Roskilde Sygehus and in the health care business in general. Lastly, this thesis has a topicality for the health care crisis of the covid-19 pandemic.

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Table of content

ACKNOWLEDGMENTS ... 2

ABSTRACT ... 3

TABLE OF CONTENT ... 4

PART 1 | PRESENTATION ... 6

INTRODUCTION ... 6

CASE:ROSKILDE SYGEHUS ... 7

RESEARCH QUESTION ... 7

DELIMITATIONS ... 8

PERSONAL MOTIVATION ... 8

OUTLINE OF THE THESIS ... 9

PART 2 | LITERATURE REVIEW ... 10

CUSTOMER EXPERIENCE ... 10

CUSTOMER JOURNEY... 12

TOUCHPOINTS ... 13

CUSTOMER JOURNEY MAP ... 16

THE PHYSICAL SURROUNDINGS ... 17

SERVICESCAPES ... 17

HEALTHSCAPES ... 20

PATIENT EXPERIENCE... 22

THE EXPERIENCE OF WAITING ROOMS ... 22

PATIENT JOURNEY ... 25

CRITIQUE... 26

PART 3 | METHODOLOGY ... 28

SOCIAL RESEARCH ... 28

EPISTEMOLOGICAL AND ONTOLOGICAL POSITION ... 29

HERMENEUTICS ... 29

RESEARCH DESIGN ... 30

ETHNOGRAPHY ... 31

THEMATIC NETWORK ANALYSIS... 36

COVID-19 ... 37

PART 4 | FINDINGS ... 38

THEMATIC NETWORK ANALYSIS ... 38

SLAGELSE SYGEHUS ... 38

ROSKILDE SYGEHUS ... 47

RECAP ... 56

EMPLOYEE PRESENTATION ... 56

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PRESENTATION OF FINDINGS ... 57

EMPLOYEE DIALOGUE ... 59

PART 5 | DISCUSSION ... 61

BASED ON THE ORGANIZING THEMES ... 61

HOW THE PHYSICAL SURROUNDINGS INFLUENCED THE EXPERIENCE ... 61

HOW THE EMOTIONS INFLUENCED THE EXPERIENCE ... 64

HOW THE EMPLOYEES INFLUENCED THE EXPERIENCE ... 68

THE PATIENT EXPERIENCE AT ROSKILDE SYGEHUS ... 69

CONTRIBUTIONS TO THE BUSINESS... 70

PROPOSITIONS FOR THE PEDIATRIC HEALTH CARE BUSINESS ... 70

FURTHER CONTRIBUTIONS TO THE BUSINESS ... 74

CONTRIBUTIONS TO THE LITERATURE ... 75

PART 6 | FINISHING REMARKS ... 77

CONCLUSION ... 77

FUTURE RESEARCH &PERSPECTIVES ... 79

BIBLIOGRAPHY ... 81

APPENDICES ... 83

APPENDIX 1,OBSERVATIONS:SLAGELSE SYGEHUS ... 83

DATE:12.04.21 ... 83

DATE:04.05.21 ... 92

APPENDIX 2,OBSERVATIONS:ROSKILDE SYGEHUS ... 98

DATE:21.04.21 ... 98

DATE:02.06.21 ... 105

DATE:07.07.21 ... 112

APPENDIX 3,THEMATIC NETWORK ANALYSIS:SLAGELSE SYGEHUS ... 117

APPENDIX 4,THEMATIC NETWORK ANALYSIS:ROSKILDE SYGEHUS ... 118

APPENDIX 5,PHOTOS:SLAGELSE SYGEHUS ... 119

APPENDIX 6,PHOTOS:ROSKILDE SYGEHUS ... 125

APPENDIX 7,PRESENTATION AT ROSKILDE SYGEHUS PEDIATRIC WARD EMPLOYEE DAY ... 130

PRESENTATION OF TEMPORARY FINDINGS ... 130

EMPLOYEE DIALOGUE ... 134

POWERPOINT PRESENTATION ... 136

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Part 1 | Presentation

The first part of the thesis is a presentation of the research area, research case and research question within. The research question will be presented with the delimitations that followed the research.

Secondly a personal motivation for the research area will be elaborated as the underlying reasons of the research area. Definitions and abbreviations are explained afterwards, and lastly, there will be an illustration of the outline of the thesis. Part 1 stands as a preparation for the further reading of the of the thesis.

Introduction

The time spent in a waiting room is often referenced to as an uncomfortable situation where the patients and relatives are in a limbo between what they know and the unknown. At a pediatric outpatient clinic, the children must be distracted so that they are not burdened with the seriousness of the situation, and the relatives must have their distracting thoughts removed so they can overcome the situation. The meaning of distraction is therefore two folded: on the one hand it can be used as a positive tool to remove the children’s focus from the negatively charged situation. On the other hand, the distracting thoughts of the relatives should be managed into a situation, where the relatives feel that they are in control so they can cope with the situation both for themselves, and ultimately for the children.

Based on an overall focus on such duality in the meaning of distraction in a waiting room, this thesis introduces considerations and suggestions for various initiatives for the health care business in general, but also for the management of the pediatric outpatient clinic at Roskilde Sygehus to consider when improving their patient experience journey. The considerations and suggestions are based on literature in the fields of customer experiences and journeys, servicescapes, healthscapes, and patient journeys, and a micro-ethnographic study in the waiting areas of two pediatric outpatient clinics, at Slagelse Sygehus and Roskilde Sygehus. In addition, this thesis contributes to literature on how to manage a patient experience journey during a pandemic.

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Case: Roskilde Sygehus

The Zealand University Hospital, Roskilde (referred to as Roskilde Sygehus) was founded in 1855 and is today one of the seven hospitals in Region Zealand1 (Region Sjælland, 2021) (Roskilde Kommune, 2021). The hospitals of Roskilde and Køge has been gathered, as the Zealand University Hospital, with two departments: Roskilde and Køge, and by 2024 the pediatric wards of Roskilde and Køge will be gathered at Køge Sygehus (Region Sjælland, 2018).

The management of the pediatric ward of Roskilde Sygehus is a relatively new management and they assess that the pediatric ward is in desperate need of some changes even though it is only for the next three years. This is where the case of the pediatric outpatient clinic of Roskilde Sygehus becomes interesting in this research because of the extraordinary opportunity to provide tangible suggestions on how to improve the waiting areas.

Research Question

The research question strives to be clear, researchable, in connections with established theories, and with the opportunity to contribute to business and literature, and lastly, the research question should neither be too broad, nor to narrow (Bryman, 2012). The following research question aims to direct some tangible considerations for the ward managers of Roskilde Sygehus, alongside with a general contribution to business and the literature on pediatric patient experience journeys:

How can the pediatric outpatient clinic of Roskilde Sygehus

improve their patient journey through the touchpoints in the waiting areas?

The outpatient clinic is for appointed consultations for patients not being hospitalized, which is also known as an ambulatory. In the literature review patient will be used in general, but as for the rest of the thesis a patient is only pediatric, either young patients (age 1-8) or youth patients (age 9-18).

All relatives observed with the patients will be described collectively as relatives, as it is not possible to know the exact relation to the patient. There will be incidents of specific relations mentioned (mother, father, brother etc.), as so because it was informed during the observations.

1 Slagelse Sygehus is also a part of Region Zealand’s seven hospitals, meaning that both Slagelse and Roskilde Sygehus are under the same organization (Region Sjælland, 2021).

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Delimitations

This thesis’ findings are delimited to the waiting areas at Slagelse Sygehus’ and Roskilde Sygehus’

pediatric outpatient clinics. Further, this thesis is delimited to the understandings from literature in the fields of customer experience and journeys, servicescapes, healthscapes, and patient journeys, meaning that the experiences of the medical treatment are not explored. To gain insight into waiting areas at pediatric outpatient clinics, this thesis is delimited to the use of qualitative research in the form of a micro-ethnography, and a validation of temporary findings from the employees at Roskilde Sygehus. A full discussion of the full patient journey and the touchpoints within at the pediatric wards of Roskilde Sygehus is beyond the scope of this research.

No foregoing research on covid-19 and the consequences that the pandemic might have had on the patient experience, including restrictions, were included in this thesis. The thesis is delimited to the inside-out approach, as the research is based on findings about the patient experience at Roskilde Sygehus. The aim is to get an understanding of the outside-in approach by observing the patient experience.

Further, the economic aspects of the found considerations and suggestions for Roskilde Sygehus is not included.

Personal Motivation

In my own childhood I was in and out of the pediatric outpatient clinic of Hvidovre Hospital over a period of years due to continuing cystitis and likely symptoms. And even though I have great memories of the employees and the cakes in the cafeteria, I also have memories of fear and being bored. The memories about the physical surroundings does not stand out as something that completely changed the narrative of the pressured situation, however, looking back it is clear to me that it is precisely the distractions in the physical surroundings that made the experience bearable as a child.

After I recently gave birth to my first child by cesarean section with a following infection and therefore stayed way longer at the hospital than usual, it is clear to me that as a patient in a hospital, there are an incredible number of thoughts that distracts you from controlling not only your own emotions, but also your child’s.

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Therefore, my professional profile and my personal stories reveal my particular perspective on how distractions can play out in several ways in a waiting room, whether you are a child who benefits from them, or you are a relative and have to fight it, and why a thorough work of distraction is a significant factor in creating the best possible experience in a waiting room for both the child and relative.

Outline of the Thesis

An outline of the thesis is presented in figure 1, showing the general structure of the thesis, divided into six parts.

Figure 1: illustration of the outline of the thesis (source: own creation)

The first part will be a presentation of the research area, research question, delimitations, personal motivation, and this outline of the thesis.

The next part will present a literature review over the literature found relevant for the research area with a focus moving from marketing streams towards the health care industry.

In part 3 the methodology is described, which includes the epistemological, ontological, and hermeneutic standpoint, followed by a presentation of the research design, including ethnography and thematic network analysis.

The next part presents the findings from the observations at the waiting areas of the pediatric outpatient clinics of Slagelse Sygehus and Roskilde Sygehus, and the findings from the employee presentation.

Part 5 is a discussion between said findings and the chosen literature for the thesis. It will end out in contributions to business and literature.

The last part will include a conclusion and suggestions for future research.

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Part 2 | Literature Review

This part of the thesis will describe the literature review on the chosen literature on customer experiences, journeys, touchpoints, and customer journey maps. It will be followed by a presentation of the chosen literature on servicescapes, healthscapes, the patient experience and journey in aiming to connect the theories together as an in-depth review on current literature found relevant for the research of this thesis.

The first part of the literature review will be concerned of customer experience as it is found to be important to understand the basics, before going into deeper knowledge of working with the customer journey. It will then be followed by theories about the customer journey and touchpoints:

how to manage it best possible from a service and marketing perspective, followed by a short presentation on how to illustrate a CJM. The literature review will then present the theories on physical surroundings from Bitner (1992), followed by a turn into more health care related literature regarding healthscapes, the patient experience and journey. The aim with this structure is to take the literature from service and marketing and apply them to the case of health care industry to get a more holistic view on the research area. In relation, many definitions from the said literature are broad and it seems to be arguable that they are applicable for the service industries within hospitals as well (Meyer & Schwager, 2007; Lemon & Verhoef, 2016; Vorhees, et al., 2017).

Customer Experience

The theory of customer experience will be applied as it is arguable that it is important to understand as a starting point for working with the customer journey. The understanding of customer experience and creating an appealing customer journey are strongly related. First, the chosen literature of customer experience will be presented, followed by the chosen literature on customer journeys and touchpoints. As a beginning on working with the customer experience Vandermerwe (1993) stated: “customers wanted functionality, not instead of but in addition to everything else”

(p. 49). In relation to this it is important for an organization to manage and create best possible customer experiences and to have a customer-centric focus (Lemon & Verhoef, 2016).

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The “customer experience is the internal and subjective response customers have to any direct or indirect contact with a company” and includes all the aspects of a product: the quality, advertising, packaging, features, ease of use and reliability (Meyer & Schwager, 2007, p. 2). One of the challenges is that the employees responsible for these areas do not have a sustained thought on how these different aspects all together influence the customer experience (Meyer & Schwager, 2007). However, as Meyer & Schwager (2007) highlights, the customer experience does not improve before it becomes the priority in all the departments of a company. Doctors, nurses, product development, service operations, human resources, accounting teams – all departments must have the patient experience in their priorities when planning and working throughout the day (Meyer &

Schwager, 2007; Lemon & Verhoef, 2016).

The understanding of customer experience has since developed into being one of the top priorities in most organizations, as it has been clear that this is what needs to be strengthened for keeping customers and thereby revenue (Lemon & Verhoef, 2016).

Current literature states that the “customer experience is a multidimensional construct focusing on a customer’s cognitive, emotional, behavioral, sensorial, and social responses to a firm’s offerings during the customer’s entire purchase journey” (Lemon & Verhoef, 2016, p. 74). By incorporating these responses, the customer experience is holistic in nature (Lemon & Verhoef, 2016).

It is questioned “how novel the customer experience focus actually is; it seems highly related to prior and existing research streams within marketing, such as customer satisfaction, service quality, relationship marketing” etc. (Lemon & Verhoef, 2016, p. 70). Hence this could be the reason why the empirical work directly on customer experience and journey is limited (Lemon & Verhoef, 2016).

Another component of customer experience is customer satisfaction, as it is focused on the customers’ cognitive evaluations of the experiences, and it could be argued that the term customer experience is broadening the concept of customer satisfaction (Lemon & Verhoef, 2016). However, changing the way of researching customers arguable enlightened and created a new way “for companies to design and deliver far richer customer experiences” (Carbone, 2003, p. 24).

This research will not go into depth with different tools for customer experience measurements, partly because there is not yet a collected agreement on robust measurements approaches to evaluate all aspects of customer experience (Lemon & Verhoef, 2016), but also because the focus

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in this thesis will be primarily on the patient journey, and thereby patient experience within.

However, the theory of customer experience is still relevant, as it takes part in analyzing the patient journey. The customer experience is being conceptualized as a dynamic process: the customer’s journey with an organization over time across multiple touchpoints (Lemon & Verhoef, 2016). Next the customer journey will be explained, followed by the presentation of literature on touchpoints.

Customer Journey

The ultimate service experience is built so that the customer gets as easy and successful way through the experience as possible (Meyer & Schwager, 2007), why it can be conceptualized with a customer journey. It is discovered that organizations that excel in delivering appealing customer journeys tend to win in the market (Maechler, Neher, & Park, 2016). The goal of the customer journey is to understand the countless possibilities a customer can take to complete their “job”

(Lemon & Verhoef, 2016).

The first understanding of a customer journey started out as a customer activity cycle with three overlapping phases: pre-purchase, purchase, and post-purchase phase (Vandermerwe, 1993;

Rosenbaum, Otalora, & Ramírez, 2017). It was used as a tool for achieving value to customers’

experiences as “whatever is known by the organization and translated commercially only becomes meaningful if, ultimately, it has a part to play in adding value to customers experiences”

(Vandermerwe, 1993, p. 51). The purchase stage is where the actual exchange takes place, leaving the pre-purchase stage as what happens before and the post-purchase stages is what happens after (Vandermerwe, 1993). It was argued that in order for an organization to be successful, the critical points in the customer activity cycle must be identified and then mapped out in an organized way to know how to prioritize and process from that on (Vandermerwe, 1993).

Vandermerwe (1993) describes how some firms started sending out their own employees to

“become” the customers and experience their brand through their customer eyes. Thereby they started seeing the products from the outside-in, and then gained a greater knowledge on how to change from the inside-out (Vandermerwe, 1993). Thence what is known as the customer journey:

pre-core service, core service, and post-core service (Vorhees, et al., 2017). Prior research was mainly focused on the customer journey starting with the customer arriving at the service experience and then ending with a check-out, and thereby neglecting the pre- and post-core periods

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(Vorhees, et al., 2017). Although throughout time the understanding of the importance of the pre- core and post-core service has been studied more thoroughly, it is still necessary to research these as service research runs the risk of becoming less relevant in the future if only focusing on the core service (Vorhees, et al., 2017). This is a strong argument in why the research of this thesis could have been broadened to study the pre- and post-core services of the pediatric outpatient clinic of Roskilde Sygehus. However, depending on how the core service is to be understood, it can be argued that the waiting room is in fact a part of the pre-core service, as the core service is when the patients (and the relatives) are in the consultation room. It can also be argued that the core service is the hospital visit in total, which starts when entering the building.

The fundamental value proposition at a hospital is to give a patient medical treatment, and first then the service quality and scope has a matter in the overall service experience too (Meyer & Schwager, 2007; Dhebar, 2012). But as it is suggested to not only focus on the core service provision (Vorhees, et al., 2017), the focus primarily will be on the waiting rooms in this thesis. As mentioned above, the experience in the waiting room can be both pre-core and core service, however it can also be post- core, as the patients and relatives sometimes need to wait for test results, information or alike after the consultations. But in the end, it would come down to what the patient experiences it as and how it was used. However, this will not be defined going forward, as the patients were not asked during the research. As the customer journey includes several interactions, perceptions and feelings happening before, during, and after the experience of the visit the journeys can be stretched into a much longer journey than what was intended by the company (Maechler, Neher, & Park, 2016).

Touchpoints

Going through the customer journey’s three stages, it is possible for the customer to interact with several touchpoints. Some of the definitions of touchpoints are: “instances of direct contact either with the product or service itself or some third party” (Meyer & Schwager, 2007, p. 3) – “individual contacts between the firm and the customer at distinct points in the experience” (Homburg et al.

2015; Schmitt, 2003, as cited in Lemon & Verhoef, 2016, p. 71) – “points of human, product, service, communication, spatial, and electronic interaction collectively constituting the interface between an enterprise and its customer over the course of the customer’s experience cycle” (Dhebar, 2012, p. 3). With these definitions it is concluded that touchpoints are the individual, direct or indirect

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interactions between the customer and the service provider over the course of the customer experience. Examples of touchpoints can be online platforms and the physical environment (Vorhees, et al., 2017), which are both represented in a hospital, alongside with touchpoints such as signs, employees, interior of the waiting rooms and so furth. It is argued that an enterprise without a holistic approach to the design, implementation, and management of customer touchpoint architecture will not be compelling for customers (Dhebar, 2012).

Dhebar (2012) suggests that for a company to have a compelling customer touchpoint architecture, it requires that they perceive themselves as hosts and the costumers as guests, for whom it is important to give a sincere welcome.

The value of touchpoints varies from patient to patient and the touchpoints are also in general not of equivalent value (Meyer & Schwager, 2007; Lemon & Verhoef, 2016). The touchpoints of highest matter are the ones that advance the patient to a subsequent and more valuable interaction (Meyer

& Schwager, 2007). The effect of the touchpoints may depend on when it occurs in the customer journey (Lemon & Verhoef, 2016). The value of a touchpoint may change over time of the customer’s life (Meyer & Schwager, 2007; Dhebar, 2012), e.g., toys may be valuable for a patient, but that same patients may find it meaningless years later, but then find it valuable years later again when coming there with their own child. It is important that the touchpoints are adaptive to these changing needs (Dhebar, 2012).

Meyer & Schwager (2007) argues that the gap between customer expectations and experience are being tested at each touchpoint for either bringing customer delight or something less. It is also important to remember that the patient’s expectations are set in part by their previous experience with the hospital, and by being children, probably with hospital visits in general (Meyer & Schwager, 2007). It is in the nature of a customer to instinctively compare each new experience, positive or otherwise, with their previous ones and judge it accordingly (Meyer & Schwager, 2007).

Lemon & Verhoef (2016) has identified four categories of touchpoints: brand-owned, partner- owned, customer-owned, and social/external/independent. All the categories can be present at each stage of the customer journey, but the strength or importance can differ in each stage (Lemon

& Verhoef, 2016).

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The brand-owned touchpoints are the ones under control of the organization, including all brand- owned media; advertising, websites, and any brand-owned elements; service convenience, parking, and cleaning (Lemon & Verhoef, 2016, pp. 77).

Partner-owned touchpoints are jointly controlled by the organization or by its partners, marketing, agencies, etc. and the line between brand-owned and partner-owned may blur (Lemon & Verhoef, 2016, pp. 77). For example, when an organization have their own app, it is a brand-owned touchpoint, but functionality updates and improvements by Apple and Google may require updates by the organizations app’s functionality and design, hence it could be argued that partners may also influence some brands-owned touchpoints (Lemon & Verhoef, 2016, pp. 77).

The customer-owned touchpoints are the actions of the customers that the organization, its partners, or others do not control or influence (Lemon & Verhoef, 2016, pp. 78). An example of this in a hospital could be of a patient’s yellow health card that is a customer-owned touchpoint but needs to interact with brand-owned touchpoints when using it at the hospital. An example could also be of the beforementioned app, which would be on a patient’s own phone, and thereby being a customer-owned touchpoint interfering with partner- and brand-owned touchpoints (Lemon &

Verhoef, 2016).

The last category of touchpoints is the social/external/independent which are the influence of other customers, peer influencers, independent information sources, environments (Lemon & Verhoef, 2016, pp. 78). At the hospital the other patients and relatives in the waiting areas can therefore be influencing touchpoints in the experience. Overall Lemon & Verhoef (2016) argues that the external environment, extreme crises, and economic situations can have a significant influence on a customer’s experience. An example of an external factor could be of the one relevant for this thesis:

an extreme crisis of the covid-19 pandemic, which is under no control of any, and can have a huge influence on the overall experience (Lemon & Verhoef, 2016).

Meyer & Schwager (2007) argues that service operations must ensure that processes, skills, and practices are attuned to every touchpoint. However, it is argued that the focus on the individual touchpoints and how to improve these needs to change to a focus on the bigger picture – the overall customer journey experienced through the customer themselves in order to really understand how to meaningfully improve the performance (Maechler, Neher, & Park, 2016). An organization also

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needs to be aware of that even if they have some appealing touchpoints, it is important to have competent employees to maintain these touchpoints. An example: a consultation room could have toys, but if the employee never takes it out and encourage the patient to play with it, the value of the touchpoint disappears (Vandermerwe, 1993).

All the touchpoints interfere with each other and develop a summary judgment of the experience (Dhebar, 2012; Vorhees, et al., 2017). An organization should choose and manage their touchpoints experience so that it differentiates from the touchpoints experience from rivals (Dhebar, 2012).

However, the rivals of Roskilde Sygehus, and other public hospital as well, are private hospitals. The nearby located hospitals of Roskilde Sygehus are all connected under one organization. This means that Slagelse and Roskilde Sygehus are not rivals, as patients will be allocated to the nearest hospital, or the hospital who is specialized in their medical condition. As the situation of the marked is stated as said, theories about rivals and competition in the market will not be taken into further depth.

Customer Journey Map

Maechler, Neher, & Park (2016) argues that “in most cases, companies are simply not naturally wired to think about the journeys their customers take” (p. 12). To change the way of thinking into a touchpoint-oriented direction can require an operational and cultural shift in the organization across functions from top to bottom (Maechler, Neher, & Park, 2016). It is argued that “for the companies that master it, the reward is higher customer and employee satisfaction” (Maechler, Neher, & Park, 2016, p. 12). One way to approach the customer journey more tangible can be by illustrating it with a customer journey map (CJM).

CJM is arguable one of the most popular tools being used to understand the customer experience and journey, however, there is still a lot of confusion on how to make a CJM best possible (Rosenbaum, Otalora, & Ramírez, 2017). The CJM is a tool where it is possible to visualize the sequence of touchpoints through which the patients and their relatives may interact with during their visit (Rosenbaum, Otalora, & Ramírez, 2017). When making a CJM the first thing to do is to identify the touchpoints in the three stages (pre-core, core, and post-core) from the customer’s point of view (Maechler, Neher, & Park, 2016; Rosenbaum, Otalora, & Ramírez, 2017). These should then be put into the CJM on a vertical axis and strategic categories alongside with relevant initiatives to develop and improve each touchpoint on the journey (Maechler, Neher, & Park, 2016;

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Rosenbaum, Otalora, & Ramírez, 2017). However, additional research on CJM will not be taken further into depth in this thesis, as there will not be a collected CJM for the pediatric outpatient clinic of Roskilde Sygehus. The said theory on CJM is still relevant, as it could be a starting point on how to start illustrating a CJM for the pediatric outpatient clinic of Roskilde Sygehus.

The Physical Surroundings

When working with the customer journey and the touchpoints within, it involves a consideration of the physical surroundings, including how the customers, patients, and employees experiences the given setting (Bitner, 1992). The impact on the physical surroundings and how it influences the behavior is particularly apparent for service organizations such as hotels, restaurants, and hospitals (Bitner, 1992). Service is produced and consumed simultaneously when the patient is in the hospital, which is why the physical surroundings of the hospital can have a strong impact on the patients’

perception of the service experience (Bitner, 1992).

It is argued that while it is common for managers to change and control the organization’s physical surroundings, it is not given, that the impact on the users is fully understood for the organizations (Bitner, 1992). The physical environment is indirectly communicating the hospitals’ image and purpose to the patients that influences the patients’ ultimate satisfaction with the service of the hospital (Bitner, 1992). The same physical surroundings that are influencing the patients may also affect the satisfaction, productivity, and motivation of the employees (Bitner, 1992). It is therefore argued that the environment of an organization should simultaneously support the needs of both the employees and the customers (Bitner, 1992).

The literature review of physical surroundings will first explain the concepts of a Servicescape (Bitner, 1992), and then of a Healthscape (Hutton & Richardson, 1995).

Servicescapes

Servicescapes explains the impact of the physical environment in a place where a service process takes place (Bitner, 1992). The dimensions of the servicescape, which is controllable by the organization includes some of the following: coloring, textures, quality of materials, furnishments, decorations, and ambient conditions: temperature, lightning, noises, music, and scent, which effects the five senses (Bitner, 1992). It is argued that controllable dimensions such as signs and symbols

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are important for an organization when customers form their first impressions (Bitner, 1992). These mentioned dimensions are the same as brand-owned touchpoints, and partly customer-owned, as noises and scent can come from other customers (Lemon & Verhoef, 2016).

The complexity of a servicescape can either be elaborate or lean (Bitner, 1992). Hotels, restaurants, and hospitals are elaborate as these servicescapes are complicated with many different elements and forms (Bitner, 1992). A lean kind of servicescape is as the one you find at a hot dog stand or at the covid-19 test center (Bitner, 1992). A hospital has many floors, rooms, sophisticated equipment, which is very elaborate, “for example, a patient’s hospital room can be designed to enhance patient comfort and satisfaction while simultaneously facilitating employee productivity” (Bitner, 1992, p.

59). An elaborated interpersonal service is given by hospital employees as they make complex decisions (Bitner, 1992). The environment influences the behavior of the individual customers and employees, and thereby influences the social interactions and the quality of it between them (Bitner, 1992). Specific physical environments can have unspoken social rules and expectations of how to behave, thus there are specific social behavior patterns associated with particular physical settings (Bitner, 1992). An example of this could be in the library, where the unspoken rule is to be quiet, or in a waiting room where there is a special focus on showing respect for the situation of others.

Environmental psychologists divide the behavior of individuals into two general, and opposite forms;

approach and avoidance (Mehrabian and Russel, 1974, as cited in Bitner, 1992, pp. 60). Approach behavior is all positive, in which the individual approach the settings being in, by showing interest, and having a desire to stay, explore and be a part of it. Avoidance is the direct opposite, and shows a desire not to stay, or take part of the setting (Bitner, 1992). Approach behavior is influenced by the perception of the environment, and it is preferable for an organization to encourage approaching behaviors from their customers and employees, for them to carry out their plans and roles in the setting (Bitner, 1992). It is thereby very important to know how to make the customers and employees avoid the avoidance behavior (Bitner, 1992). A servicescape encouraging approach behavior could be when stores hand out free samples, herein encouraging customers to approach the store. Bitner (1992) further states, that organizations can manage the success of the consumer experience by letting the servicescape direct the consumers in the right directions and executing

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their plans once inside their physical surroundings (Bitner, 1992). It is therefore stated that “Positive (negative) internal responses lead to approach (avoidance) behaviors” (Bitner, 1992, p. 61).

When designing a physical environment, it can be challenging to encourage approach behaviors as the optimal settings for one person, may not be the optimal settings for another (Bitner, 1992).

Further, it can be challenging to design a physical environment in which approach behaviors is encouraged by both the customers and the employees, as their needs can be very different from one another (Bitner, 1992). Bitner (1992) states that in order to design a physical environment the first step must be “to identify desirable customer and/or employee behaviors and the strategic goals that the organization hopes to advance through its physical facility” (p. 62), which arguable would be relevant in designing a customer journey as well. Bitner (1992) also suggest that “perceptions of greater control in the servicescape increase pleasure” (p. 63), thus it should be desired to offer as many possibilities for control by the touchpoints as possible.

Because a hospital is an interpersonal servicescape, it would be concerned with both customer and employee behaviors, the effects of the physical setting on the interactions between and among customers and employees (Bitner, 1992). Interpersonal meaning that the service is performed by both the customer and employees within the servicescape (Bitner, 1992). It is argued that the ambient conditions are very important for satisfying the customers and employees in an interpersonal servicescape (Bitner, 1992).

The perception of the servicescape influences how we perceive the products (Bitner, 1992). It can be argued that a hospital and a waiting room are in themselves unpleasant environment, as you almost never go there expecting a great experience with a high feeling of pleasure. Therefore, it could be nice to challenge this, as it is maybe in these situations a person is somehow most in need of a good experience. In addition to said perceived servicescape, it also has an influence on the emotional responses and behavior, and “the emotional-eliciting qualities of environments are captured by two dimensions: pleasant-displeasure and degree of arousal (i.e., amount of stimulation or excitement)” (Bitner, 1992, p. 63). The more pleasure one feels in a specific setting, the more time and money the person wants to spend there. Unpleasant environments are avoided (Bitner, 1992). The degree of arousal depends on whether the environment is viewed as being pleasant. An unpleasant environment can be high in arousal with noises, lots of stimulations, and confusion,

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which leads to a negative impact and avoidance (Bitner, 1992). Tivoli is a great example of a place where the feeling of pleasure is usually high and at the same time contains a high amount of stimulation and excitement. But then again, Tivoli can have the opposite effect on different people, as the way people experience stimulations are very different. Bitner (1992) divides the ways of experience stimulations into five response moderators: Arousal-seeker: enjoys and looks for high levels of stimulations – Arousal-avoider: prefers lower levels of stimulation – Screeners of stimuli:

able to experience high levels of stimulation without being affected by it – Nonscreeners: would be highly affected and might exhibit extreme responses even to low levels of stimulation (pp. 65). Thus, individual personality traits can affect how a servicescape is being perceived, as it can also depend on the reasons for being there and can vary from time to time (Bitner, 1992).

Healthscapes

As the understanding and development of the servicescapes took a larger interest so did of the atmospherics concerning healthcare, thus the word Healthscapes (Hutton & Richardson, 1995). It is argued that “atmospheres are comprehended through four of the five senses: sight, sound, scent, and touch (we do not taste our environmental surrounding, although an argument can be made for the food to be part of the physical environment at a hospital” (Kotler, 1973, as cited in Hutton &

Richardson, 1995, p. 52). Based on this and the definition on servicescapes Bitner (1992), Hutton &

Richardson (1995) concludes that “atmospherics + servicescapes = healthscapes” (p. 54).

Hutton & Richardson (1995) argues that an appealing healthscape can have a positive impact on a patient’s healing process and physical well-being of other participants in the environment. It is important to manage the healthscape, as a hospital can be unfamiliar and frightening, which can challenge a persons’ emotions and physical well-being (Hutton & Richardson, 1995).

The healthscape has an impact on patients, relatives, and employees, however it is argued that there can be “not enough” and “too much” healthscapes; the first being: unattractiveness, dirt, disorganization, and the latter being: overdone décor making the patient wonder “who is paying for all this” (Hutton & Richardson, 1995). Thus, the goal for a healthscape must be to find the golden mean. Hutton & Richardson (1995) provides suggestions on how to find this.

“Environments must be kept clean, organized, pleasant smelling, and comfortable (…) All areas of health facilities must be accessible to as much light as possible. Noise and temperature levels must

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be monitored and maintained” (Hutton & Richardson, 1995, p. 59). However, it is suggested that hospitals should not look cold and sterile, yet still look like a health service facility and not like something it is not, “as people favor typical and familiar surroundings” (Hutton & Richardson, 1995, p. 59). It can be argued if this is still the case and that many businesses in fact strive to go out of the standard settings to differentiative themselves. An example could be the restaurant Noma2 where the experience is based on being nothing like a restaurant visit but more of a holistic experience.

The same goes with the waiting rooms of a hospital, which instead of looking like the familiar surroundings of a hospital, could look like the familiar surroundings from a living room, and for children from a kindergarten. Moreover, it is also suggested that a health care facility should be designed to satisfy the target patients group for a higher satisfaction of the said facility (Hutton &

Richardson, 1995), which is why it is important that a waiting room at a pediatric ward is designed to satisfy the children who are to use it.

It is suggested that even though it can be relevant to hire consultants, an organization should be familiar with all the different aspects of the business and thereby not rely only on the hired consultant (Hutton & Richardson, 1995), this is aligned with literature mentioned earlier in this thesis on how employees needs to be familiar with the touchpoints in the customer journey (Meyer

& Schwager, 2007; Lemon & Verhoef, 2016).

It is important to remember that because of the patient journey being somehow circular (if going back to the same hospital), expectations can be higher or lower than they were the last time. In general, the expectations can vary a big deal from patient to patient, as all people are different and have different minds (Hutton & Richardson, 1995). This argument is known from the earlier mentioned marketing research, on how expectations are set in part by previous experience (Meyer

& Schwager, 2007). The gap between perceptions of quality attributes and outcomes can cause quality dissatisfaction, when expectations exactly meet the perceptions it can cause satisfaction, and lastly, when performance goes beyond expectations, a high level of satisfaction can occur (Hutton & Richardson, 1995). Hutton & Richardson (1995) argues that the health care service quality gap failure is very likely to occur. As it is highly difficult for a typical patient to determine the

2 Noma is a restaurant located in Copenhagen serving New Nordic Cuisine. Noma has been nominated for Worlds Best

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competence of the health care employees and the chosen medical procedure, the patients are most likely to use the tangible signals (the physical environment) to evaluate the overall service experience (Hutton & Richardson, 1995).

A critique on the research on the physical environment; servicescapes by Bitner (1992) and healthscapes Hutton & Richardson (1995) could be on the relevance of it, as it is some of the older literature used in this thesis. It is however found that both Bitner’s (1992) and Hutton & Richardson’s (1995) contributions to this field is in some way the underlying theories for the composition of the research in this thesis, combined with newer research from marketing streams (Meyer & Schwager, 2007; Dhebar, 2012; Maechler, Neher, & Park, 2016; Vorhees, et al., 2017).

However, it is still arguable that some of the suggestions provided by Hutton & Richardson (1995) could be outdated, as the needs of a healthscape, and therein a waiting room changes over time many different aspects, an example being technology. As the needs changes so does the perceptions of quality, expectations, and what gives satisfaction. But as it is suggested the healthscape must be managed, thus it must also be managed so it is updated on what the patients need and expect (Hutton & Richardson, 1995).

Patient Experience

The literature on customer experience, journeys, and touchpoints combined with literature on the physical surroundings gives the necessary viewpoint to dig deeper into literature in a direct concern of the research question. Thus, the next literature is concerned with pediatric waiting rooms (Corsano, Majorano, Vignola, Guidotti, & Izzi, 2015) and the patient experience journey (Gualandi, Masella, Viglione, & Tartaglini, 2019).

The Experience of Waiting Rooms

From some of the earlier literature on this area the waiting time spent in a hospital’s waiting room is associated with high stress and discomfort (Corsano, Majorano, Vignola, Guidotti, & Izzi, 2015).

Some of the findings on how to make the time in the waiting room more pleasant relies on assurance, comfort, support, information, and a caring behavior from the employees (Corsano, Majorano, Vignola, Guidotti, & Izzi, 2015). The waiting room is also a place where patients and their

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relatives are sharing emotions with others and the physical surroundings of the waiting room should support such aspects (Corsano, Majorano, Vignola, Guidotti, & Izzi, 2015). It has earlier been observed that there is “a positive correlation between more attractive waiting rooms and higher levels of satisfaction, a reduction of patients anxiety and a perceived higher quality care (Becker and Douglass, 2008, as cited in Corsano, Majorano, Vignola, Guidotti, & Izzi, 2015, p. 1067). However, most studies in earlier literature on this area has focused on the waiting rooms in intensive care or in critical conditions, whereas the research by Corsano, Majorano, Vignola, Guidotti, & Izzi (2015) is focused on the waiting rooms in the ambulatory care and the importance of positive activities such as playing that can help distract the children while waiting. This is particularly relevant at the pediatric outpatient clinic in Roskilde Hospital and therefor also in this thesis, as it is concerned with the same type of waiting areas.

“Playing in the waiting room is an opportunity for young patients to express and elaborate negative emotions, such as anxiety and fear” (Pedro et al.,2007, as cited in Corsano, Majorano, Vignola, Guidotti, & Izzi, 2015, p. 1067). It is highlighted that when children participate in playing activities before a clinical visit, they establish harmonious relations with their companions and health professionals and feel less anxious and afraid (Corsano, Majorano, Vignola, Guidotti, & Izzi, 2015).

More studies have found similar findings, and it has therefore been concluded in studies that it is necessary for the waiting rooms in pediatric ambulatory wards to be equipped with toys and pleasant physical spaces in order to help the children relax and cope better with their medical care (Corsano, Majorano, Vignola, Guidotti, & Izzi, 2015).

The waiting time for both the children and their relatives can involve different types of feelings such as boredom, fear of painful treatment or tests, and concerns about the outcomes of their treatments and tests (Corsano, Majorano, Vignola, Guidotti, & Izzi, 2015). It is argued that because hospitalized children’s negative emotions are associated with a greater perception of pain (Caldas et al, 2004 cited in (Corsano, Majorano, Vignola, Guidotti, & Izzi, 2015)), it is particularly important to investigate children’s emotional states in hospital waiting rooms. Therefore, the concern of the study of Corsano, Majorano, Vignola, Guidotti, & Izzi (2015) is to examine young patients’ emotional states in the families’ perceptions of waiting.

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The study was qualitative data in form of drawings by the children and it was found that how terrified, afraid, and nervous the patients felt, was proportionally to how many medical instruments that were drawn (Corsano, Majorano, Vignola, Guidotti, & Izzi, 2015). Earlier studies in these areas suggests that the drawings of the medical instruments can be an attempt to control one’s anxiety about the disease or the reality perceived as uncertain and painful, as of why this approach was used (Corsano et al., 2013, as cited in (Corsano, Majorano, Vignola, Guidotti, & Izzi, 2015).

As for the adults (relatives) is was found that the feelings of boredom, stress, anxiety, and fear of test results were present in most of them, however at the same time they accepted the waiting time in which they found help in the presence of other adults and the possibility to share emotions in order to relax and to fill out the waiting time (Corsano, Majorano, Vignola, Guidotti, & Izzi, 2015).

Due to the findings of low level of negative emotions and the presence of a high percentage of boredom among the patients, it is discussed if the waiting time at a day hospital is considered a routine, well-known, and necessary. This was also why some of the adults liked more presence of entertainment activities in the waiting room (Corsano, Majorano, Vignola, Guidotti, & Izzi, 2015).

The younger patients felt more frightened than the older, which can have something to do with the pain of the medical tests, the developmental stages of the younger children’s body and knowledge of pain within, whereas older children probably understand more about their diseases and the procedures (Corsano, Majorano, Vignola, Guidotti, & Izzi, 2015). Even though the level of measured anxiety was low, the older children showed higher anxiety levels than the younger ones, which might also reflect on the fact that older children probably understand more about their diseases and have a higher awareness of their conditions.

The research by Corsano, Majorano, Vignola, Guidotti, & Izzi (2015) provides an insight on the perceived experience of young pediatric patients and their parents in a pediatric waiting room at a day hospital (outpatient clinic) in Italy. It is important to remember that another waiting room in another hospital could, even though similar in its physical surroundings, be perceived completely different. The governmental and cultural differences from Italy to Denmark can influence if the research can be applicable to the findings in this thesis.

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Patient Journey

Gualandi, Masella, Viglione, & Tartaglini (2019) states that research and health care management on patient experience earlier have focused on how to achieve effective clinical pathway care and by increasing patient adherence to treatment, which can fail to reveal aspects that are relevant to patients that influences the experience and perception of quality of the service (Gualandi, Masella, Viglione, & Tartaglini, 2019). Gualandi, Masella, Viglione, & Tartaglini (2019) argues that even though the patient experience of healthcare is emerging as an important area of knowledge, it is also still being overlooked. “In the hospital context, the patient journey is a key cross-functional business process where patients and providers share action and information flows between people and systems across various touchpoints” (Gualandi, Masella, Viglione, & Tartaglini, 2019, p. 2).

The reasons of why and how to manage the patient journey are similar with the customer journey:

the patients are the ones who experience and knows the touchpoints of the journey best which is the reason why “hospitals can significantly improve the quality of the service provided by exploring and understanding the individual patient journey” (Gualandi, Masella, Viglione, & Tartaglini, 2019, p. 2).

Through their study they found that the relationship between the patient and professionals were important (Gualandi, Masella, Viglione, & Tartaglini, 2019). In particular when the patients are in vulnerable situations. One of the health care employee informants tells how it helps to apologize for delays with a smile, so that the patients still feel taken care of (Gualandi, Masella, Viglione, &

Tartaglini, 2019). Another of the health care employee informants is aware of her importance as a nurse, as she is the first person to meet the patient, it is important to orientate them correctly in the ward (Gualandi, Masella, Viglione, & Tartaglini, 2019). And there is an overall agreement that as professionals it is important to be able to calm patients though their stay and before surgeries (Gualandi, Masella, Viglione, & Tartaglini, 2019). The value of a personalized relationship improving the patients experience was recognized by both the patients and the health care employees, as it was recognized that a good relationship can compensate for the hospital’s inefficiencies, e.g., when apologizing for delays (Gualandi, Masella, Viglione, & Tartaglini, 2019). In addition, it was found that the relationship was extremely important with patients in critical situations (Gualandi, Masella, Viglione, & Tartaglini, 2019).

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The waiting time for relatives while the patient was in the operating room seemed endless and the lack of information caused anxiety which led the health care employees to recognize the importance of informing the relatives about the patient’s clinic pathway during surgery (Gualandi, Masella, Viglione, & Tartaglini, 2019). The lack of information was found to have an impact on the patients when they did not receive any information about the outcome of their clinic examination or procedures related to their hospitalization (Gualandi, Masella, Viglione, & Tartaglini, 2019).

Similar to the earlier mentioned literature it is crucial for the hospitals to understand what they can do to improve the touchpoints in their patient’s journeys (Gualandi, Masella, Viglione, & Tartaglini, 2019). The same goes for Roskilde Sygehus.

This research is important for the thesis, as it gives firsthand insights on how the patient journey was experienced for a group of eight patients and the health care employees at a hospital (Gualandi, Masella, Viglione, & Tartaglini, 2019). However, it can be difficult to generalize the findings from the research as being the situation for all patients at all hospitals, as a minor change in the context can change the situation (Gualandi, Masella, Viglione, & Tartaglini, 2019).

There is governmental and cultural changes from Italy to Denmark which can have a great influence on the findings if a similar study were to be carried out at a Danish Hospital.

Lastly, in the study of Gualandi, Masella, Viglione, & Tartaglini (2019) the data was collected on adult patients, and not pediatric patients, as this thesis is concerned. This was taken into consideration when reviewing which arguments to use in the discussion of this thesis.

Critique

It is important to state that in many countries, probably including the ones in the literature mentioned above, the service of a hospital is more privatized, and paid for in person or by health insurances. In Denmark all citizens have the right to go a public hospital without a direct payment.

The public hospitals are owned and paid by the government and thus the citizens pay by the taxes.

Further, some of the first mentioned literature and theories is based on service-, marketing- or other industries and thereby does not take into consideration how it could be applicable in the healthcare industry and specifically at hospitals. Though the intension of the literature reviews has been to take

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the former known theories from service and marketing and applying it to the case of the health care industry in Denmark, hereunder Roskilde Sygehus. It is arguable if this is succeeded as much of the literature regarding the health care industry confirms and states many of the same points, however, the first part of the literature is still found to be relevant as it states the common assumptions from marketing and add to a more comprehensive and holistic view on how to manage the touchpoints of the patient experience journey.

Moreover, it can be discussed whether this litterature review is fulfilling (enough) as one can also dig deeper into the literature on the given topic. The review could also have gone in other directions, and thereby gone deeper into topics such as health care satisfaction, the differences between what the pediatric patient experience opposed to what the relatives experience, or the prioritization of process over patients.

Research on covid-19 and the consequences it might have had on the patient journey, including restrictions, were not included. Partly because the research was limited and partly because the research area on this thesis were set before the covid-19 pandemic took over. The literature is therefore included as general theoretical perspectives on the experience of a waiting room;

however, one cannot escape the fact that the covid-19 pandemic has made the situation so unique and the experience of waiting rooms so extraordinarily special that the universality of literature may not be used in the same way as one normally could. Many of the literature's considerations and conclusions do not depend on a society in a health crisis, like the covid-19 pandemic. Therefore, it is important that the further work has a pragmatic and rigorous focus on the unique situation and the specific waiting rooms with covid-19 restrictions and not just consider it another waiting room.

The literature must therefore, more than usual, be regarded as an underlying theoretical background, and not clear theoretical answers to the empirical data.

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Part 3 | Methodology

This part aims to describe the chosen methodology for the thesis. First the nature and process of social research will be explained including the epistemological and ontological positions, and how the hermeneutic approach is applicable for the research. Second, there will be a presentation of the research design and how the data is collected through a micro ethnography and how it was coded through thematic network analysis. Lastly there will be some reflections on the effects of covid-19.

Social Research

Social research is concerned about the topics relevant to the social scientific fields, such as human geography, social policy, and sociology, among others (Bryman, 2012). As this thesis is written in the field of sociology it is social research. Social research is based and influenced by the theories already available on a given topic, as in this research takes earlier litterature and theories on the topic into account, and contributes to said theory, because the findings will feed into the knowledge of the topic (Bryman, 2012).

In social research the training and personal values of the researcher will have influence on the research area, research questions, and the methods used throughout the research (Bryman, 2012).

Hence, social research can carry the risk of research being restricted to what they know, and not using suitable method for a research question (Bryman, 2012). In addition, it also carries the risk of not being a neat and linear process but is rather characterized by contingency and navigation through the unexpected (Bryman, 2012). However, Carbone (2003) states that modern neurological research shows how conclusions are not drawn in linear, hierarchical, exclusively conscious ways, but by gleaning cues and bits together from all senses to create complex impression as a basis for preference, loyalty, and advocacy. Which is not only relevant in how this research of this thesis will take form, but also for the research question, and how the patients experience the waiting areas.

Nevertheless, it is argued that the risks of not having a neat and linear process are a crucial part of social research, and to predict the outcome of the research will never be a possibility. Social research is most often supported by a case study to illustrate an example of the researched theory (Bryman, 2012). Thus one of the reasons for applying a case study in this thesis, that of Roskilde Sygehus.

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